Tuesday, February 22, 2005



Complementary Nutrition Therapies in Children

Nutrition 530

Beth Ogata, MS, RD

bogata@u.washington.edu

May 25, 2005

WHAT IS COMPLEMENTARY NUTRITION?

a. Definitions, other terminology

• Allopathic Medicine

• Alternative Medicine

• Complementary Medicine

• Complementary and Alternative Medicine (CAM) – Integrated Medicine

• National Center for Complementary and Alternative Medicine (NCCAM) identifies 5 major categories:

1. Alternative medical systems (e.g., Traditional Chinese medicine, Ayurvedic Medicine)

2. Mind-body interventions (e.g., meditation, prayer)

3. Biologically-based therapies (e.g., herbs, foods, vitamins)

4. Manipulative and body-based methods (e.g., chiropractic or osteopathic manipulation)

5. Energy therapies (e.g., qi gong, Reiki, therapeutic touch)

• Homeopathy

• Naturopathy

• Herbal medicine

• Product entrepreneurs and lecture sales

b. Prevalence

• US in general

• Among children, including children with special health care needs

• Where do families get information about CAM?

• Why the increasing use of CAM?

c. Potential problems

• Safety concerns

1. perception that natural = safe

2. contaminants

3. mistaken plants

4. current use vs. traditional use

5. special circumstances, including interactions with medications

• Evidence related to efficacy

• Family resources

• Most research, training not specific to children

d. Regulation

• Dietary Supplement Health and Education Act of 1994 (DSHEA):

1. manufacturer can claim a product affects the body’s structure or function, but cannot claim that a product is effective for the prevention or treatment of a specific disease (“reduces stress and frustration” vs. “antidepressant”)

2. label must include a disclaimer informing users that the FDA has not evaluated the agent

3. manufacturer responsible for controlling quality and safety; if a safety concern arises, FDA must prove that the product is unsafe

• Other safeguards

1. United States Pharmacopoeia (USP)

2. Good Manufacturing Practice (GMP)

3. International Standards Organization (ISO)

COMMON THERAPIES USED WITH CHILDREN

e. Common herbal supplements (Table 1)

f. Disorder-specific therapies (Table 2)

• ADHD

• Autism

• Cystic fibrosis

• Down syndrome

g. Therapies with potential toxicities (Table 3)

GUIDELINES FOR CONSIDERING ALTERMATIVE THERAPIES

h. Is the product safe?

i. What is the cost to the family?

j. Is there evidence to support the use of a supplement or special diet?

k. Will this augment or replace conventional therapy?

l. How will the therapy be evaluated?

• What will be monitored?

• Which change related to which therapy?

m. What are the possible harmful effects?

• Nutrients being eliminated? In excess?

• Effect on food pattern?

• Expense? Resources

SUPPORTING FAMILIES USING CAM

n. Element of Family-Centered Care: Sharing of unbiased and complete information in an appropriate and supportive manner

I am an optimist and a realist.

I know that there are no miracle cures for autism.

Yet, I am not afraid to dream of the day when there might be,

I still hold onto that dream.

Even if it is with the nail on my little finger

o. ADA Code of Ethics: The dietetics professional must practice dietetics based on scientific principles and current information and provide sufficient information to enable clients to make their own informed decisions

p. American Academy of Pediatrics

• Seek information and be prepared to share it with families

• Evaluate the scientific merits of specific therapeutic approaches

• Identify risks or potential harmful effects

• Provide families with information on a range of treatment options

• Educate families to evaluate information about all treatment approaches

• Avoid dismissal of CAM in ways that communicate a lack of sensitivity or concern for the family’s perspective

• Recognize feeling threatened and guard against becoming defensive

• If the CAM approach is endorsed, offer to assist in monitoring and evaluating the response

• Actively listen to the family and the child with chronic illness

q. Legal issues

• Include use of CAM in nutrition assessment

• RDs who recommend herbal supplements are assuming a significant risk

• Document, document, document (Holland)

1. Anthropometric data: Alterations in growth can occur with restricted diets

2. Dietary intake: Note excesses or deficiencies in nutrients and general food categories. Long-term elimination of certain food groups (e.g., milk) without compensations can lead to dietary deficiencies (e.g., calcium)

3. Food and plant allergies/intolerances: Patients with known plant allergies may exhibit reactions with herbal products from the same family

4. Current intake of supplements: Identify the types of supplements the child is currently taking, including the dosage, duration of use, who recommended the product and if the primary physician is aware

5. Caregiver’s plans for implementation: Make note of the proposed treatment the caregivers are considering. Document your response to the proposed treatment

CASE EXAMPLE

RESOURCES

r. Websites

s. Journals and textbooks

t. Community or hospital pharmacy

u. Families and clients

v. Local CAM practitioners

QUESTIONS & ANSWERS

Complementary Nutrition and Kids

RESOURCES

– US Food and Drug Administration

nccam. – NIH’s National Center for Complementary and Alternative Medicine. Includes information about specific treatments: nccam.health/bytreatment.htm, and lists studies that are under way.

– Herb Research Foundation

– independently tests products

– Nutrition in Complementary Care Practice Group

– National Council for Reliable Health Information is a private, nonprofit health agency that focuses on health misinformation, fraud and quackery.

Fragakis A. The Health Professional’s Guide to Popular Dietary Supplements, 2nd ed. American Dietetic Association. 2003. Purchase at: Public/ProductCatalog/104.cfm

cfsan.~dms/supplmnt.html - US FDA, Center for Food Safety and Applied Nutrition – site provides information about US regulatory issues around dietary supplements, including a recent (November 2004) public meeting.

dietary-. – NIH Office of Dietary Supplements established as part of DSHEA legislation; maintains the International Bibliographic Information on Dietary Supplements (IBIDS) database

International Bibliographic Information on Dietary Supplements (IBIDS) database; ods.od.Health_Information/IBIDS.aspx - includes published international scientific literature on dietary supplements, vitamins, minerals, and botanicals

nlm.medlineplus/complementaryandalternativetherapies.html - Medline Plus: Complementary and Alternative Therapies; information for families and practitioners includes acupuncture, alternative medicine, botanicals and herbal medicine, cancer alternative therapy, chiropractic, and dietary supplements.

REFERENCES

American Academy of Pediatrics, Committee on Children with Disabilities. Counseling families who choose complementary and alternative medicine for their child with chronic illness or disability. Pediatrics. 2001;107(3):598-601. This policy statement is available online: aappolicy.cgi/content/full/pediatrics;107/3/598.

Anding R, Campbell J. The safety and efficacy of herbal therapy: what your patients need to know. Building Block for Life. 2000; 24(1). Available online to PNPG members: (Click on Members Only, then navigate to Building Block archives)

Atwood KC. Naturopathy: A critical appraisal. Medscape General Medicine. 2003;5(4). Online: viewarticle/465994_print. Accessed 12/30/2004.

Ball SD, Kertesz D, Moyer-Mileur LJ. Dietary supplement use is prevalent among children with a chronic illness. J Am Diet Assoc. 2005;105:78-84.

Casey S. Complementary Nutrition Therapies in Pediatrics. Nutrition Focus. 1999;14(5). This article reviews some of the common types of complementary and alternative therapies used by families of children with special health care needs and provides some guidelines for RDs and other health care professionals. A back issue can be ordered: depts.washington.edu/chdd/ucedd/CO/co_NutriFocus.html.

DeSmet P. Herbal remedies. New Engl J Med. 2002;347(25):2046-56.

Ernst E. Harmless herbs? A review of the recent literature. Am J Med. 1998;104(2):170-8.

Garrard J, Harms S, Eberly LE, Matiak A. Variations in product choices of frequently purchased herbs. Arch Intern Med. 2003;163:2290-2295.

Holland M. Communicating with families concerning the use of complementary or alternative nutritional therapies. Building Block for Life. 2000; 24(1). Available online to PNPG members: (Click on Members Only, then navigate to Building Block archives) This issue of the Building Block also includes an article about the use of CAM among families with CF and an extensive list of resources and references for the use of complementary and herbal medicine.

Hrastinger A, Dietz B, Bauer R, Sagraves R, Mahady G. Is there clinical evidence supporting the use of botanical dietary supplements in children? J Pediatr. 2005; 146:311-317.

Ize-Ludlow D, Ragone S, Bruck IS, Bernstein JN, Duchowny M, Garcia Pena BM. Neurotoxicities in infants seen with the consumption of star anise tea. Pediatrics. 2004;114(5):e653-e656. Online: cgi/doi/10.1542/peds.2004-0058.

Lee ACC, Kemper KJ. Homeopathy and Naturopathy: Practice characteristics and pediatric care. Arch Pediatr Adolesc Med. 2000; 154:75-80.

O’Hara M, Kiefer D, Farrell K, Kemper K. A review of 12 commonly used medicinal herbs. Arch Fam Med. 1998;7:523-536.

Vohra S, Schlenker J, Anding R. Complementary and alternative medicine and pediatrics: Focus on herbal products and nutritional therapy. Building Block for Life. 2004;28(1). Available online to PNPG members: (Click on Members Only, then navigate to Building Block archives.)

Table 1: Selected herbal products and comments on their use

|Product |Form |Purported use |Comment or caution |

|Aloe |Topical, oral |Topical: dermatitis, herpes, wound |Topical: may delay wound healing |

| | |healing, psoriasis |Oral: diarrhea, hypokalemia |

| | |Oral: constipation |Inconclusive evidence |

|Cayenne pepper |Powder or ointment |External: chronic pain |Can be irritating to the intestinal tract |

|(capsicum) | |Internal: GI stimulant | |

|Chamomile |Tea, compress |Mild sedative, mild spasmolytic, wound|Considered safe |

| | |healing | |

|Coltsfoot |Tea, cough drops |Antitussive, demulcent |May be hepatotoxic and carcinogenic |

|Comfrey |Tea, poultice, |Healing agent, antispasmotic |May be hepatotoxic |

| |extract | | |

|Cranberry |Capsules, extract |Prevent, treat UTI, antioxidant |No effectiveness noted in catheterized children |

|Echinacea |Capsule, liquid, |Anti-infective, immune stimulant |Efficacy shown in some studies, not in others |

| |dried extract, |Treatment and prevention of URI, |Rash, pruitis, dizziness, unclear long-term |

| |tincture |common cold |effects on immune system |

| | |Wound healing, antimicrobial |May ↓effectiveness of immunosuppressant |

| | | |medications |

| | | |Species determines effectiveness |

| | | |Contraindicated for children with allergies to |

| | | |Asteraceae (daisy) family |

|Ephedra (Ma Huang) |Tablet; cut herb |Nervous system stimulant |May cause hypertension, tachycardia, myocardial |

| | |Anti-asthmatic, decongestant |infarction, stroke, psychosis, death |

| | |Weight loss, performance enhancement |Banned by FDA, but available through websites |

|Evening Primrose Oil |Oil, administered |Essential fatty acids (gamma-linoleic |May be effective for atopic dermatitis; effects |

| |orally |acid) for treatment in atopic eczema, |on ADHD unclear; may alter fatty |

| | |ADHD, rheumatoid arthritis, diabetic |acid/prostaglandin metabolism in children w/ |

| | |neuropathy, others |diabetes, effects on neuropathy unclear |

|Garlic |Fresh, minced |Hypertension, hypercholesterolemia, |Side effects include GI upset, gas, reflux, |

| |Pills, powder |atherosclerosis |nausea, antiplatelet effects; probable modest |

| | | |effect for ↓ing lipids and blood pressure, though|

| | | |not shown in 1 pediatric study |

| | | |Increases effect of warfarin |

|Ginseng |Extract |General health promotion, athletic |Potential medication interactions: interact with |

| |Root, pills |ability, energy, fertility, others |wafarin, potentiate effects of CNS stimulants and|

| | | |hypoglycemic agents, ↓ effectiveness of |

| | | |immunosuppressants |

| | | |Contraindicated in HTN, CVD, hypotension, |

| | | |diabetes |

|Goldenseal |Tea |Digestive aid |May be effective for localized relief because of |

| | |URI, common cold |astringent properties |

| | | |Side effects may include diarrhea, HTN, |

| | | |vasoconstriction |

|Horehound |Candy, cough drops |Expectorant, cough suppressant |FDA indicates safe as a food additive |

| | | |May not be effective |

|Kava kava |Dry, extract |Euphoric effect, stress |Side effects can include dizziness, skin |

| | | |yellowing, CNS depression |

| | | |Do not use with barbiturates, antipsychotics, or |

| | | |alcohol |

| | | |Contraindicated among children ................
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