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Use of alternative therapies by patients presenting to a pediatric emergency department
The Journal of Emergency Medicine, Vol. 28, No. 3, pp. 267–271, 2005 Copyright © 2005 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/05 $–see front matter
doi:10.1016/j.jemermed.2004.11.019
Original Contributions
USE OF ALTERNATIVE THERAPIES BY PATIENTS PRESENTING TO A PEDIATRIC EMERGENCY DEPARTMENT Andrea Losier,
BSc Med, MD,*
Brett Taylor,
MD,†‡
and Conrad Vincent Fernandez,
MD‡§
*Department of Emergency Medicine, Children’s Hospital of Eastern Ontario, Ottawa, Ontario, Canada, †Department of Emergency Medicine, IWK Health Centre, Halifax, Nova Scotia, Canada, ‡Dalhousie University, Halifax, Nova Scotia, Canada, and §Department of Pediatrics, IWK Health Centre, Halifax, Nova Scotia, Canada Reprint Address: Conrad Fernandez, MD, IWK Health Centre, 5850 University Avenue, Halifax, Nova Scotia B3J 3G9, Canada
e Abstract—Complementary and alternative medicine (CAM) is used by some patients to supplement their health care. Information on the use of CAM in children who are not chronically ill is sparse. We conducted a survey of caregivers presenting to a tertiary pediatric Emergency Department to determine CAM use in this population. Six hundred twenty questionnaires (77.6% of those distributed) were available for analysis. Approximately 13% of caregivers reported using CAM for their child. The most common CAM therapies used were homeopathy (20%), prayer/ spiritual approaches (19.7%), and massage therapy (16.7%). Age of child greater than 1 year was associated with CAM use (p < 0.05), as was parental higher education (p < 0.0001). Income, ethnicity, parental age, and chronic illness were not correlated with CAM use. CAM therapies are infrequently used in pediatric patients presenting to the Emergency Department. © 2005 Elsevier Inc.
care. The use of alternative medicine is increasing. In one study in 1990, 34% of adults reported using at least one unconventional therapy in the previous year (1). A repeat survey by the same authors in 1997 reported that the number had increased to 42.1% (2). A survey in Canada showed the that use of herbal preparations doubled between 1996 and 1998 (3). Patients with serious chronic illnesses such as cystic fibrosis, juvenile arthritis, and cancer are more likely to use CAM (4 – 8); respectively, 66%, 70%, and 46% of patients had used some form of non-conventional treatment. Most of these patients had used complementary and alternative therapies as an adjunct with more conventional or allopathic treatment. A study in 2003 assessed the use of CAM by families with children with special needs. Sixty-four percent reported using CAM for their child. Use rate was 24% in children whose conditions were evaluated as correctable compared with a use rate of 76% in children whose conditions were evaluated as non-repairable (9). Andrews et al. in 1998 demonstrated that 55% of children with asthma in their study had used CAM (10). Information on the use of complementary and alternative medicine in children who are not chronically ill is sparse. A study in 1994 of patients in a pediatric outpatient clinic in Canada showed that 11% of children consulted one or more alternative medicine practitioners (11). Three major characteristics differentiated users
e Keywords— complementary and alternative medicine; pediatrics; emergency department; homeopathy; acute illness
INTRODUCTION Complementary and alternative medicine (CAM) are practices that are not an integral part of the conventional health care system in the United States (US) and Canada but are used by some patients to supplement their health
RECEIVED: 5 March 2004; ACCEPTED: 17 November 2004 267
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from non-users of complementary medicine: the child’s age (⬎ 1 year), parental use of CAM, and higher maternal education. Studies in outpatient pediatric clinics in the US have demonstrated use of CAM in 12–21% of children (12,13). A study in patients presenting to an urban Emergency Department (ED) in the US found that 12% of parents had used CAM to treat their child (14). Homeopathic and naturopathic remedies were the most often used therapies. Lanski et al. in 2003, more specifically, examined the use of herbal therapies in families presenting to an urban pediatric ED (15). Forty-five percent of caregivers reported giving their children an herbal product, 27% of whom were given three or more in the past year (15). These studies have the following limitations: Lanski et al. had a relatively small sample size and limited the study to use of herbal preparations only (15). Pitetti et al. had a much larger sample size, however, the data were collected in a US urban emergency department (14). The results of this study may not be applicable to the pediatric population presenting to a Canadian emergency department. Numerous studies have indicated that patients do not routinely inform their conventional health care givers that they are using CAM therapies (11–13). Reasons for this are myriad and include fear of ridicule, and belief that their primary care physician would have little information on CAM practices. A survey in the United States of 348 pediatricians’ experience with CAM demonstrated that almost 84% believed that some of their patients used CAM. However, 55% believed that this constituted less than 10% of their patients (16). Given this apparent disconnect, it is important to clearly define how frequently CAM is used and we therefore have chosen to look at an unselected population presenting to the ED. Complementary and alternative therapies have been shown to be beneficial (17–21). However, specific adverse events have been reported in the literature for many complementary and alternative therapies (4,21–23). As CAM therapies may have an impact upon health and on recommendations for parents in the ED, a good understanding of the frequency, reasons for use and disclosure is important. Our study seeks to examine all types of CAM therapies used by families in treating their children in a Canadian urban center. The objectives of this study were: to determine the frequency of use of complementary and alternative therapies in children presenting to a pediatric emergency department, which types of alternative therapies are being used, reasons for their use, and if parents inform their primary care physicians about their use of alternative therapies.
A. Losier et al.
METHODS This study was carried out over an 8-month period (October 2001 to May 2002) in the Emergency Department at the IWK Health Centre for Women, Children and Families in Halifax, Nova Scotia, Canada. Questions for the survey were developed from those of a previous survey of pediatric oncology patients by Fernandez et al. (8). Questionnaires were offered to random families by the ward clerk while they were registering their child in the ED. A total of 800 questionnaires were given to parents or guardians in the ED. The completed questionnaires were handed back to the nurse taking care of the child. Exclusion criteria were: 1) previously filled out questionnaire, 2) inability to read or write English, 3) resuscitation/emergent patients, 4) children unaccompanied by a parent or guardian, and 5) patients with emotional issues such as child abuse or psychiatric problems. All other patients were eligible for the study. The questionnaire was completely anonymous. Consent to participate in the study was implied by return of a completed questionnaire. The questionnaire consisted of 37 multiple-choice questions. Basic demographic data were collected. Specific questions about CAM use included: 1) CAM therapy use in the child, 2) in other members of the family, 3) types of CAM used, 4) sources of information about CAM, 5) reasons for using or not using CAM, and 6) level of satisfaction with their use of CAM. Caregivers were asked if their child had any chronic medical problems, and if so were asked to list their child’s medical problems and any prescription or over-the-counter medication used to treat the condition. Parents were also asked if they had informed their physician or pharmacist about the use of alternative therapies and the reasons why, if they had not informed their health care providers. A pilot questionnaire was conducted to ensure the readability and clarity of the questions. Twenty questionnaires were distributed to consecutive families presenting to the ED. Minor revisions were made to the questionnaire, mainly involving the layout of the questionnaire. Survey results were entered into a computerized database. Statistical analysis was performed using Epi Info 2000 version 1.1.2. (Epi Info, Centers for Disease Control, Atlanta, GA). Frequencies of responses to questionnaire items that solicit information on caregivers’ use of CAM were tallied. Univariate analyses examined relationships between independent variables (e.g., parental income) and the variable of interest (CAM use) using the Mantel-Haenszel chi-square test or Fisher’s exact test, where appropriate. Alpha was set at 0.05 for all significance tests. The study was approved and conducted in accordance with the ethical standards set by
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Table 1. Age Distribution of Children Represented by Respondents to the Questionnaire Child’s Age (years)
Frequency (%)
⬍1 2–5 6–10 11–16 Mean age of total population
106 (17.3) 230 (37.6) 145 (23.7) 131 (21.4) 5.9 ⫾ 4.5
the Research Ethics Board at the IWK Health Centre, where the study was conducted.
RESULTS There were 621 questionnaires returned of the 800 distributed (77.6%). One questionnaire was not entered into the database as it had no questions answered on it. Thus, 620 questionnaires were available for data analysis. Not every question was answered on every questionnaire. Only 12.8% of parents had used CAM for their child (75/588). The characteristics of the responding participants are shown in Tables 1 and 2. Seventy-two percent of respondents who filled out the questionnaire had education beyond high school. Over 91% of the participants in the study were white. Eighty-five percent of the questionnaires were filled out by the mother. Approximately one-third of respondents identified their child as having a chronic illness (168/613, 27.4%). The most common diagnoses were: asthma (93, 45.8%), otitis media (12, 5.9%), eczema (11, 5.4%), and attention deficit hyperactivity disorder (ADHD) (10, 4.9%). CAM use was associated with higher education (p ⬍ 0.001); and age of the child greater than 1 year (p ⬍ 0.05). Thirty-six percent of the study population had an income of greater than $60,000 per annum. Only 12% of respondents had an income of less than $20,000 per year. CAM use was not associated with income (p ⫽ 0.3); ethnicity (p ⫽ 0.54); chronic illness (p ⫽ 0.49); parental age (p ⫽ 0.1), or other family members’ use of CAM (p ⫽ 0.76). A comparison of families using and not using CAM is presented in Table 3. Parents who used CAM discussed their use of CAM
Table 2. Age Distribution of Parents who Responded to the Questionnaire Parent’s Age (years)
Frequency (%)
16–25 26–35 36–45 46⫹
70 (11.3) 284 (46.0) 227 (36.8) 36 (5.8)
Table 3. Comparison of Respondents to the Questionnaire who Reported using CAM in Contrast to Those not Using CAM Characteristic Mean age of child in years (SD) Ethnicity (%) White Black Other Education level Grade/High school College/university
Using CAM
Not Using CAM
p Value
7.19 (⫾ 4.49)
5.7 (⫾ 4.38)
0.05 0.09
70 (93.3%) 2 (2.7%) 3 (4.0%)
466 (91.2%) 21 (4.1%) 24 (4.7%)
9 (5.6%) 66 (15.5%)
151 (94.4%) 361 (84.5%)
0.001
with their doctor (54/75, 72%) and pharmacist (39/75, 52%) relatively frequently. Twenty-three percent of respondents indicated their sources of information on alternative and complementary medicine (140/604). The most common sources of information were as follows: the media (86/111, 77.5%), health food stores (71/100, 71%), friends (72/106, 67.9%), naturopath/homeopath (51/91, 56%), Internet (44/94, 46.8%), pharmacist (33/ 80, 41.2%), family (27/79, 34.2%), and physician (34.1%). Parents indicated that 26.7% of their children were using therapies prescribed by a practitioner of CAM (20/75). The majority of respondents that used CAM, used them in conjunction with conventional therapies (56/74, 75.7%). Ninety-one percent of respondents indicated that CAM was either helpful or very helpful when used to treat their child (63/69, 91.3%). Eightynine percent indicated that they would use complementary and alternative therapies again. Over 88% of parents stated that they would recommend CAM therapies for other children with the same condition as their child. The most common CAM therapies used regularly were: homeopathy (20%), prayer/spiritual approaches (19.7%), massage therapy (16.7%), play/art/music therapy (16.7%), special diets (11.3%), herbal extracts (9.9%), chiropractic (9.2%), and high-dose vitamins (8.3%) (Figure 1). Of the respondents who used CAM for their child, the most common reasons for use were: that CAM was more holistic (48/72, 66.7%), more natural (44/68, 64.7%), fit with their personal beliefs about health/life (42/69, 60.9%), and that they had more control in personal health decisions (30/66, 45.5%). Over one-third of respondents reported unhappiness with regular medical treatment as a reason to use CAM (21/67, 31.3%). Only 28% of respondents indicated that their reason to use CAM in their child was due to recommendation by family or friends (18/64, 28.1%). Of the respondents who did not use complementary and alternative therapies, the reasons for not using CAM
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A. Losier et al.
Figure 1. Types of CAM therapies reported by parents for pediatric patients visiting an Emergency Department.
were that medical treatment was working (178/379, 47%), fear of side effects (115/375, 30.7%), and fear of the unknown (82/382, 21.5%). Interestingly, 45.9% (173/ 377) would have considered CAM if regular medical treatment was not working.
DISCUSSION In this study, 12.8% of caregivers used complementary and alternative medicine for their child. This percentage is comparable to that reported by Spigelblatt et al. in a general pediatric outpatient clinic in Montreal, Canada as well as that reported by Pitetti et al. in an urban pediatric Emergency Department in the US (11,14). This shows a remarkable stability over 10 years despite an apparent increase in adult usage of CAM. Homeopathy was the most common CAM therapy used to treat a child in our study. This is similar to that reported by Pittetti et al. (14). However, prayer/spiritual approaches and massage therapy were reported almost as commonly. Of interest, 72% of respondents who used CAM discussed their use of CAM with their primary care physician. This is higher than reported in previous studies except for that of Pitetti et al., who reported a similar percentage (11,13,14). This increase in caregivers discussing the use of CAM with their physician, as compared with earlier studies, may be due to the increase in use of CAM practices in the general population over time; increasing comfort of users of CAM to discuss alternative practices with their primary care physicians; or an increase in physicians asking patients about complementary health care practices. Still, a substantial portion of families did not discuss their use of CAM with their primary care physician. This is of concern in that health care providers are not necessarily aware of these practices, and studies have shown that nurses and doctors do not routinely ask about CAM use in their patients.
Some complementary practices such as herbal medications or teas can have interactions with medications prescribed by physicians. If we are not aware of these practices, there is the potential to misdiagnose or not realize that a significant adverse event has taken place. The most common reasons for using CAM were that CAM was more holistic and natural and fit better with families’ personal beliefs about health. One-third of caregivers who used CAM were unhappy with regular medical treatment, but three-quarters of respondents chose to use CAM in conjunction with regular medical treatment. Twenty-six percent of respondents believed that CAM therapies were safer than conventional treatments. However, many herbal remedies have been associated with adverse effects and some have interactions with overthe-counter and prescription medications (23–25). Thus, continuing education of parents and families is important. Previous studies have indicated that a major reason to use CAM therapies was recommendations by families and friends. In comparison with previous studies, only 28% of families in this study used CAM on the basis of recommendations of family and friends. Twenty-three percent of respondents indicated their sources of information on complementary and alternative therapies. The most common source of information was from the media (77.5%), followed by information from health food stores (71%) and friends (67.9%). Over 46% of respondents received information via the Internet. Information from pharmacists and physicians was reported in 41% and 34%, respectively. This is of significance in that families report that they are gathering information about CAM from sources that may not be using evidence-based approaches. Our study has the following limitations. We do not know how the non-respondents view CAM therapies, although there were few non-respondents. Only 35% of respondents were from rural areas and, therefore, were not well represented in this study. This may be an area of further research, to determine if rural and urban differences exist in the use of complementary and alternative therapies. Our respondents tended to have a relatively high income, high level of education, and be of Caucasian background, as has been seen in other studies in this setting (26). In this Emergency Department study, we were able to sample a large number of patients and families in a relatively short time, which should assist in offsetting some of the above limitations. Twenty-one of the parents who used complementary and alternative therapies indicated their hope that physicians receive training about CAM. Many were disappointed that their primary care physicians did not have information about alternative choices in health care. Of those that commented, most believed that both CAM and
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conventional medicine have a role in patient health. They also indicated that patients and families needed to take a more proactive role in educating themselves about therapies both conventional and alternative.
8.
9.
CONCLUSION AND FUTURE DIRECTIONS Our study contributes important information to the understanding of CAM use in pediatric patients distinct from previous studies that targeted specific populations with chronic illness. CAM therapies are infrequently used to treat children who present to the Emergency Department. However, it remains important to determine the use of CAM in individual children to understand more fully all aspects of their health. Our study also confirms and highlights that many families do not discuss the use of CAM with conventional health care givers. Future research should focus on further understanding of the use of CAM in our patients in different populations and settings, so that we may understand the frequency and motivation of CAM use in these groups of patients.
10.
11. 12.
13.
14.
15.
16.
17.
Acknowledgment—This study was funded by a Category A grant from Research Services at the IWK Health Centre.
18. 19. 20.
REFERENCES 1. Eisenberg DM, Kessler RC, Foster C, Norlock FE, Calkins DR, Delbanco TL. Unconventional medicine in the United States. Prevalence, costs, and patterns of use. N Engl J Med 1993;328:246 –52. 2. 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 –75. 3. Sibbald B. New federal office will spend millions to regulate herbal remedies, vitamins. CMAJ 1999;160:1355–7. 4. Spigelblatt LS. Alternative medicine: should it be used in children? Curr Probl Pediatr 1995;25:180 – 8. 5. Southwood TR, Malleson PN, Mahy M. Unconventional remedies used for patients with juvenile arthritis. Pediatrics 1990;85:150 – 4. 6. Stern RC, Canada ER, Doershuk CF. Use of nonmedicinal treatment of cystic fibrosis patients. J Adolesc Health 1992;160:612–5. 7. Sawyer MG, Gannoni AF, Toogood IR, Antoniou G, Rice M. The
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use of alternative therapies by children with cancer. Med J Aust 1994;160:320 –2. Fernandez CV, Stutzer C, MacWilliam L, Fryer C. Alternative and complementary medicine use in pediatric oncology patients in British Columbia; prevalence of and reasons for use or non-use. J Clin Oncol 1998,16:1279 – 86. Sanders H, Davis MF, Duncan B, Meaney FJ, Haynes J, Barton LL. Use of complementary and alternative medical therapies among children with special health care needs in southern Arizona. Pediatrics 2003;111:584 –7. Andrews L, Lokuge S, Sawyer M, Lillywhite L, Kennedy D, Martin J. The use of alternative therapies by children with asthma; a brief report. J Paediatr Child Health 1998;34:131– 4. Spigelblatt L, Laine-Ammara G, Pless IB, Guyver A. The use of alternative medicine by children. Pediatrics 1994;94:811– 4. Ottolini MC, Hamburger EK, Loprieato JO, et al. Complementary and alternative medicine use among children in the Washington, DC area. Ambul Pediatr 2001;1:122–5. Sawni-Sikand A, Schubiner H, Thomas RL. Use of complementary/alternative therapies among children in primary care pediatrics. Ambul Pediatr 2002;2:99 –103. Pitetti R, Singh S, Hornyak D, Garcia SE, Herr S. Complementary and alternative medicine use in children. Pediatr Emerg Care 2001;17:165–9. Lanski SL, Greenwald M, Perkins A, Simon HK. Herbal therapy use in a pediatric emergency department population: expect the unexpected. Pediatrics 2003;111:981–5. Sikand A, Laken M. Pediatricians’ experience with and attitudes toward complementary/alternative medicine. Arch Pediatr Adolesc Med 1998;152:1059 – 64. Kemper, KJ. Separation and synthesis: a holistic approach to therapeutics. Pediatr Rev 1996;17:279 – 83. Buck M, Michel RS. Talking with families about herbal therapies. J Pediatr 2000;136:673– 8. Weizman Z, Alkrinawi S, Goldfarb D, Bitran C. Efficacy of herbal tea preparation in infantile colic. J Pediatr 1993;122:650 –2. Linde K, Ramirez G, Mulrow CD, Pauls A, Weidenhammer W, Melchart D. St. John’s Wort for depression-an overview and metaanalysis of randomized clinical trials. BMJ 1996;313:253– 8. Woolf AD. Herbal remedies and children: do they work? Are they harmful? Pediatrics 2003;112:240 – 6. Jurgens T. The risks and benefits associated with the use of herbal medicines: facts for the health care practitioner. Drugs Ther Marit Pract 1999;22:25–32. Ernst E. Serious adverse effects of unconventional therapies for children and adolescents: a systematic review of recent evidence. Eur J Pediatr 2003;162:72– 80. Ernst E. Harmless herbs? A review of recent literature. Am J Med 1998;104:170 – 8. Tomassoni AJ, Simone K. Herbal medicine for children: an illusion of safety? Curr Opin Pediatr 2001;13:162–9. Fernandez CV, Gordon K, Van Den Hof M, Baylis F. Knowledge and attitudes of pregnant women with regard to collection, testing and banking of cord blood stem cells. CMAJ 2003;168:695– 8.
doi:10.1016/j.jemermed.2004.11.019
Original Contributions
USE OF ALTERNATIVE THERAPIES BY PATIENTS PRESENTING TO A PEDIATRIC EMERGENCY DEPARTMENT Andrea Losier,
BSc Med, MD,*
Brett Taylor,
MD,†‡
and Conrad Vincent Fernandez,
MD‡§
*Department of Emergency Medicine, Children’s Hospital of Eastern Ontario, Ottawa, Ontario, Canada, †Department of Emergency Medicine, IWK Health Centre, Halifax, Nova Scotia, Canada, ‡Dalhousie University, Halifax, Nova Scotia, Canada, and §Department of Pediatrics, IWK Health Centre, Halifax, Nova Scotia, Canada Reprint Address: Conrad Fernandez, MD, IWK Health Centre, 5850 University Avenue, Halifax, Nova Scotia B3J 3G9, Canada
e Abstract—Complementary and alternative medicine (CAM) is used by some patients to supplement their health care. Information on the use of CAM in children who are not chronically ill is sparse. We conducted a survey of caregivers presenting to a tertiary pediatric Emergency Department to determine CAM use in this population. Six hundred twenty questionnaires (77.6% of those distributed) were available for analysis. Approximately 13% of caregivers reported using CAM for their child. The most common CAM therapies used were homeopathy (20%), prayer/ spiritual approaches (19.7%), and massage therapy (16.7%). Age of child greater than 1 year was associated with CAM use (p < 0.05), as was parental higher education (p < 0.0001). Income, ethnicity, parental age, and chronic illness were not correlated with CAM use. CAM therapies are infrequently used in pediatric patients presenting to the Emergency Department. © 2005 Elsevier Inc.
care. The use of alternative medicine is increasing. In one study in 1990, 34% of adults reported using at least one unconventional therapy in the previous year (1). A repeat survey by the same authors in 1997 reported that the number had increased to 42.1% (2). A survey in Canada showed the that use of herbal preparations doubled between 1996 and 1998 (3). Patients with serious chronic illnesses such as cystic fibrosis, juvenile arthritis, and cancer are more likely to use CAM (4 – 8); respectively, 66%, 70%, and 46% of patients had used some form of non-conventional treatment. Most of these patients had used complementary and alternative therapies as an adjunct with more conventional or allopathic treatment. A study in 2003 assessed the use of CAM by families with children with special needs. Sixty-four percent reported using CAM for their child. Use rate was 24% in children whose conditions were evaluated as correctable compared with a use rate of 76% in children whose conditions were evaluated as non-repairable (9). Andrews et al. in 1998 demonstrated that 55% of children with asthma in their study had used CAM (10). Information on the use of complementary and alternative medicine in children who are not chronically ill is sparse. A study in 1994 of patients in a pediatric outpatient clinic in Canada showed that 11% of children consulted one or more alternative medicine practitioners (11). Three major characteristics differentiated users
e Keywords— complementary and alternative medicine; pediatrics; emergency department; homeopathy; acute illness
INTRODUCTION Complementary and alternative medicine (CAM) are practices that are not an integral part of the conventional health care system in the United States (US) and Canada but are used by some patients to supplement their health
RECEIVED: 5 March 2004; ACCEPTED: 17 November 2004 267
268
from non-users of complementary medicine: the child’s age (⬎ 1 year), parental use of CAM, and higher maternal education. Studies in outpatient pediatric clinics in the US have demonstrated use of CAM in 12–21% of children (12,13). A study in patients presenting to an urban Emergency Department (ED) in the US found that 12% of parents had used CAM to treat their child (14). Homeopathic and naturopathic remedies were the most often used therapies. Lanski et al. in 2003, more specifically, examined the use of herbal therapies in families presenting to an urban pediatric ED (15). Forty-five percent of caregivers reported giving their children an herbal product, 27% of whom were given three or more in the past year (15). These studies have the following limitations: Lanski et al. had a relatively small sample size and limited the study to use of herbal preparations only (15). Pitetti et al. had a much larger sample size, however, the data were collected in a US urban emergency department (14). The results of this study may not be applicable to the pediatric population presenting to a Canadian emergency department. Numerous studies have indicated that patients do not routinely inform their conventional health care givers that they are using CAM therapies (11–13). Reasons for this are myriad and include fear of ridicule, and belief that their primary care physician would have little information on CAM practices. A survey in the United States of 348 pediatricians’ experience with CAM demonstrated that almost 84% believed that some of their patients used CAM. However, 55% believed that this constituted less than 10% of their patients (16). Given this apparent disconnect, it is important to clearly define how frequently CAM is used and we therefore have chosen to look at an unselected population presenting to the ED. Complementary and alternative therapies have been shown to be beneficial (17–21). However, specific adverse events have been reported in the literature for many complementary and alternative therapies (4,21–23). As CAM therapies may have an impact upon health and on recommendations for parents in the ED, a good understanding of the frequency, reasons for use and disclosure is important. Our study seeks to examine all types of CAM therapies used by families in treating their children in a Canadian urban center. The objectives of this study were: to determine the frequency of use of complementary and alternative therapies in children presenting to a pediatric emergency department, which types of alternative therapies are being used, reasons for their use, and if parents inform their primary care physicians about their use of alternative therapies.
A. Losier et al.
METHODS This study was carried out over an 8-month period (October 2001 to May 2002) in the Emergency Department at the IWK Health Centre for Women, Children and Families in Halifax, Nova Scotia, Canada. Questions for the survey were developed from those of a previous survey of pediatric oncology patients by Fernandez et al. (8). Questionnaires were offered to random families by the ward clerk while they were registering their child in the ED. A total of 800 questionnaires were given to parents or guardians in the ED. The completed questionnaires were handed back to the nurse taking care of the child. Exclusion criteria were: 1) previously filled out questionnaire, 2) inability to read or write English, 3) resuscitation/emergent patients, 4) children unaccompanied by a parent or guardian, and 5) patients with emotional issues such as child abuse or psychiatric problems. All other patients were eligible for the study. The questionnaire was completely anonymous. Consent to participate in the study was implied by return of a completed questionnaire. The questionnaire consisted of 37 multiple-choice questions. Basic demographic data were collected. Specific questions about CAM use included: 1) CAM therapy use in the child, 2) in other members of the family, 3) types of CAM used, 4) sources of information about CAM, 5) reasons for using or not using CAM, and 6) level of satisfaction with their use of CAM. Caregivers were asked if their child had any chronic medical problems, and if so were asked to list their child’s medical problems and any prescription or over-the-counter medication used to treat the condition. Parents were also asked if they had informed their physician or pharmacist about the use of alternative therapies and the reasons why, if they had not informed their health care providers. A pilot questionnaire was conducted to ensure the readability and clarity of the questions. Twenty questionnaires were distributed to consecutive families presenting to the ED. Minor revisions were made to the questionnaire, mainly involving the layout of the questionnaire. Survey results were entered into a computerized database. Statistical analysis was performed using Epi Info 2000 version 1.1.2. (Epi Info, Centers for Disease Control, Atlanta, GA). Frequencies of responses to questionnaire items that solicit information on caregivers’ use of CAM were tallied. Univariate analyses examined relationships between independent variables (e.g., parental income) and the variable of interest (CAM use) using the Mantel-Haenszel chi-square test or Fisher’s exact test, where appropriate. Alpha was set at 0.05 for all significance tests. The study was approved and conducted in accordance with the ethical standards set by
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Table 1. Age Distribution of Children Represented by Respondents to the Questionnaire Child’s Age (years)
Frequency (%)
⬍1 2–5 6–10 11–16 Mean age of total population
106 (17.3) 230 (37.6) 145 (23.7) 131 (21.4) 5.9 ⫾ 4.5
the Research Ethics Board at the IWK Health Centre, where the study was conducted.
RESULTS There were 621 questionnaires returned of the 800 distributed (77.6%). One questionnaire was not entered into the database as it had no questions answered on it. Thus, 620 questionnaires were available for data analysis. Not every question was answered on every questionnaire. Only 12.8% of parents had used CAM for their child (75/588). The characteristics of the responding participants are shown in Tables 1 and 2. Seventy-two percent of respondents who filled out the questionnaire had education beyond high school. Over 91% of the participants in the study were white. Eighty-five percent of the questionnaires were filled out by the mother. Approximately one-third of respondents identified their child as having a chronic illness (168/613, 27.4%). The most common diagnoses were: asthma (93, 45.8%), otitis media (12, 5.9%), eczema (11, 5.4%), and attention deficit hyperactivity disorder (ADHD) (10, 4.9%). CAM use was associated with higher education (p ⬍ 0.001); and age of the child greater than 1 year (p ⬍ 0.05). Thirty-six percent of the study population had an income of greater than $60,000 per annum. Only 12% of respondents had an income of less than $20,000 per year. CAM use was not associated with income (p ⫽ 0.3); ethnicity (p ⫽ 0.54); chronic illness (p ⫽ 0.49); parental age (p ⫽ 0.1), or other family members’ use of CAM (p ⫽ 0.76). A comparison of families using and not using CAM is presented in Table 3. Parents who used CAM discussed their use of CAM
Table 2. Age Distribution of Parents who Responded to the Questionnaire Parent’s Age (years)
Frequency (%)
16–25 26–35 36–45 46⫹
70 (11.3) 284 (46.0) 227 (36.8) 36 (5.8)
Table 3. Comparison of Respondents to the Questionnaire who Reported using CAM in Contrast to Those not Using CAM Characteristic Mean age of child in years (SD) Ethnicity (%) White Black Other Education level Grade/High school College/university
Using CAM
Not Using CAM
p Value
7.19 (⫾ 4.49)
5.7 (⫾ 4.38)
0.05 0.09
70 (93.3%) 2 (2.7%) 3 (4.0%)
466 (91.2%) 21 (4.1%) 24 (4.7%)
9 (5.6%) 66 (15.5%)
151 (94.4%) 361 (84.5%)
0.001
with their doctor (54/75, 72%) and pharmacist (39/75, 52%) relatively frequently. Twenty-three percent of respondents indicated their sources of information on alternative and complementary medicine (140/604). The most common sources of information were as follows: the media (86/111, 77.5%), health food stores (71/100, 71%), friends (72/106, 67.9%), naturopath/homeopath (51/91, 56%), Internet (44/94, 46.8%), pharmacist (33/ 80, 41.2%), family (27/79, 34.2%), and physician (34.1%). Parents indicated that 26.7% of their children were using therapies prescribed by a practitioner of CAM (20/75). The majority of respondents that used CAM, used them in conjunction with conventional therapies (56/74, 75.7%). Ninety-one percent of respondents indicated that CAM was either helpful or very helpful when used to treat their child (63/69, 91.3%). Eightynine percent indicated that they would use complementary and alternative therapies again. Over 88% of parents stated that they would recommend CAM therapies for other children with the same condition as their child. The most common CAM therapies used regularly were: homeopathy (20%), prayer/spiritual approaches (19.7%), massage therapy (16.7%), play/art/music therapy (16.7%), special diets (11.3%), herbal extracts (9.9%), chiropractic (9.2%), and high-dose vitamins (8.3%) (Figure 1). Of the respondents who used CAM for their child, the most common reasons for use were: that CAM was more holistic (48/72, 66.7%), more natural (44/68, 64.7%), fit with their personal beliefs about health/life (42/69, 60.9%), and that they had more control in personal health decisions (30/66, 45.5%). Over one-third of respondents reported unhappiness with regular medical treatment as a reason to use CAM (21/67, 31.3%). Only 28% of respondents indicated that their reason to use CAM in their child was due to recommendation by family or friends (18/64, 28.1%). Of the respondents who did not use complementary and alternative therapies, the reasons for not using CAM
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Figure 1. Types of CAM therapies reported by parents for pediatric patients visiting an Emergency Department.
were that medical treatment was working (178/379, 47%), fear of side effects (115/375, 30.7%), and fear of the unknown (82/382, 21.5%). Interestingly, 45.9% (173/ 377) would have considered CAM if regular medical treatment was not working.
DISCUSSION In this study, 12.8% of caregivers used complementary and alternative medicine for their child. This percentage is comparable to that reported by Spigelblatt et al. in a general pediatric outpatient clinic in Montreal, Canada as well as that reported by Pitetti et al. in an urban pediatric Emergency Department in the US (11,14). This shows a remarkable stability over 10 years despite an apparent increase in adult usage of CAM. Homeopathy was the most common CAM therapy used to treat a child in our study. This is similar to that reported by Pittetti et al. (14). However, prayer/spiritual approaches and massage therapy were reported almost as commonly. Of interest, 72% of respondents who used CAM discussed their use of CAM with their primary care physician. This is higher than reported in previous studies except for that of Pitetti et al., who reported a similar percentage (11,13,14). This increase in caregivers discussing the use of CAM with their physician, as compared with earlier studies, may be due to the increase in use of CAM practices in the general population over time; increasing comfort of users of CAM to discuss alternative practices with their primary care physicians; or an increase in physicians asking patients about complementary health care practices. Still, a substantial portion of families did not discuss their use of CAM with their primary care physician. This is of concern in that health care providers are not necessarily aware of these practices, and studies have shown that nurses and doctors do not routinely ask about CAM use in their patients.
Some complementary practices such as herbal medications or teas can have interactions with medications prescribed by physicians. If we are not aware of these practices, there is the potential to misdiagnose or not realize that a significant adverse event has taken place. The most common reasons for using CAM were that CAM was more holistic and natural and fit better with families’ personal beliefs about health. One-third of caregivers who used CAM were unhappy with regular medical treatment, but three-quarters of respondents chose to use CAM in conjunction with regular medical treatment. Twenty-six percent of respondents believed that CAM therapies were safer than conventional treatments. However, many herbal remedies have been associated with adverse effects and some have interactions with overthe-counter and prescription medications (23–25). Thus, continuing education of parents and families is important. Previous studies have indicated that a major reason to use CAM therapies was recommendations by families and friends. In comparison with previous studies, only 28% of families in this study used CAM on the basis of recommendations of family and friends. Twenty-three percent of respondents indicated their sources of information on complementary and alternative therapies. The most common source of information was from the media (77.5%), followed by information from health food stores (71%) and friends (67.9%). Over 46% of respondents received information via the Internet. Information from pharmacists and physicians was reported in 41% and 34%, respectively. This is of significance in that families report that they are gathering information about CAM from sources that may not be using evidence-based approaches. Our study has the following limitations. We do not know how the non-respondents view CAM therapies, although there were few non-respondents. Only 35% of respondents were from rural areas and, therefore, were not well represented in this study. This may be an area of further research, to determine if rural and urban differences exist in the use of complementary and alternative therapies. Our respondents tended to have a relatively high income, high level of education, and be of Caucasian background, as has been seen in other studies in this setting (26). In this Emergency Department study, we were able to sample a large number of patients and families in a relatively short time, which should assist in offsetting some of the above limitations. Twenty-one of the parents who used complementary and alternative therapies indicated their hope that physicians receive training about CAM. Many were disappointed that their primary care physicians did not have information about alternative choices in health care. Of those that commented, most believed that both CAM and
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conventional medicine have a role in patient health. They also indicated that patients and families needed to take a more proactive role in educating themselves about therapies both conventional and alternative.
8.
9.
CONCLUSION AND FUTURE DIRECTIONS Our study contributes important information to the understanding of CAM use in pediatric patients distinct from previous studies that targeted specific populations with chronic illness. CAM therapies are infrequently used to treat children who present to the Emergency Department. However, it remains important to determine the use of CAM in individual children to understand more fully all aspects of their health. Our study also confirms and highlights that many families do not discuss the use of CAM with conventional health care givers. Future research should focus on further understanding of the use of CAM in our patients in different populations and settings, so that we may understand the frequency and motivation of CAM use in these groups of patients.
10.
11. 12.
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14.
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Acknowledgment—This study was funded by a Category A grant from Research Services at the IWK Health Centre.
18. 19. 20.
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