Adolescent Health Care: A Practical Guide

Chapter 83

Complementary and Alternative Medicine in Adolescents

Cora Collette Breuner

Michael Cirigliano

Complementary and alternative medicine (CAM), also known as integrative, non-allopathic, unconventional, holistic, or natural therapy, encompasses a whole spectrum of healing resources, modalities, and practices other than those intrinsic to the conventional, traditional health systems in a particular society.

One study reported that in 1990 more than one third of Americans used “unconventional” therapies (Eisenberg, 1997). This number increased by 38% between 1990 and 1997. Expenditures for visits to alternative medicine providers were estimated at $21.2 billion and more than half was paid from out of pocket. Approximately one in five people taking prescription medicines were also taking herbs or high-dose vitamin supplements.

CAM use in children and adolescents is more common in certain geographic areas of North America and in young people with chronic illnesses. Importantly, homeless youth have a 70% utilization rate for CAM. In order of prevalence, the therapies most frequently used were chiropractic, homeopathy, naturopathy, and acupuncture. Parents who use CAM for their children and adolescents are older and have a higher level of maternal education. Medical conditions most frequently treated with CAM include respiratory (including ears, nose, and throat), musculoskeletal, skin, gastrointestinal (GI), allergies, chronic conditions such as cystic fibrosis, cancer, arthritis, and illnesses that require surgery.

Important Issues for the Health Care Provider

Knowledge/Open Discussion

It is imperative that the adolescent or their parents inform their health care provider regarding CAM use in order to appropriately answer questions that are brought to them. If the provider is open to the discussion of CAM, the teen or parent is less likely to rely on erroneous and false information gleaned from friends, family, and the Internet. Clearly, if health care providers embrace this approach, rather than having a negative or critical attitude, patients will benefit and receive accurate information.

Medicolegal Issues

The combination of lack of sufficient medical research and the desire of the patient to utilize alternative treatments may present an ethical dilemma for the health care provider. There is genuine concern for patient safety, as well as the potential for medicolegal issues. According to Cohen and Kemper (2005), important questions for patients, families, and health care providers who elect to use CAM include:

  • Will effective care be utilized when the patient's condition is life threatening?
  • Will using CAM treatments prevent the use of conventional treatment?
  • What is known about the safety and/or efficacy of the treatment?
  • Has the patient consented to the use of CAM?
  • Will this proposed CAM therapy be acceptable to another clinician?
  • Does this treatment have some support in the medical literature?

In many instances, it is not the health care provider who wishes to use such a treatment but the patient. The health care provider must then decide what to recommend. The health care provider should provide advice that is based on the best available evidence and is congruent with the patient's personal needs and the clinician's best judgment.

Adequate Medical History

Health care providers need to ask adolescents about their use of any form of CAM during every office visit, given that adolescents use CAM (including taking herbal products or supplements). Many herbal treatments have the potential to interact with standard pharmaceutical agents. Screening for CAM use may prevent a significant drug–herb interaction or treatment complication. It also allows the health care provider to assess whether all treatments are actually necessary. Young people may not report CAM use because they believe that their health care provider will not approve or that their health care provider will have insufficient information about CAM

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modalities. Health care providers involved in adolescent health care should be knowledgeable regarding the use of CAM including side effects, toxicity, and potential interactions. Health care providers should also inform adolescents that just because something is natural, does not guarantee its safety.

Herbal Therapies

Consumer use of herbal therapies has increased over the last several years. Sales of herbal therapies have increased yearly by approximately 5% to 6% until recently when sales have stabilized. Despite concerns among the medical community, consumer use remains popular and is rarely discussed with the health care provider. Given the overwhelming popularity of herbal therapies, health care providers should be encouraged to follow basic clinical guidelines to ensure patient safety (Table 83.1).

TABLE 83.1
Guidelines for Use of Herbal Therapies in the Clinical Setting

From The review of natural products. St. Louis, MO: Facts and Comparisons, 1999, with permission.

All patients should be asked about use of alternative/complementary treatments during routine office visits and initial visits

Care should be exercised when combining herbal therapies with standard pharmaceuticals

Because herbal contaminants have been documented in a number of products due to poor manufacturing and lack of standardization, use of herbal therapies by reputable manufacturers is advised

Larger than recommended doses of herbal therapies should be discouraged

Until safety data exist, herbal therapies should not be used in pregnancy or lactation

Long-term use of herbal therapies should be done only under the supervision of a knowledgeable health care provider

Herbal therapies with known toxicity and side effects should not be used in children and adolescents

Use of herbal stimulants and performance enhancers in the adolescent population should be discouraged

All proven treatment options should be discussed with patients and their families before entertaining any form of complementary therapies

Regulation

The Dietary Supplement Health and Education Act (DSHEA) of 1994 defines herbal therapies as supplements. As such, herbal therapies are not tested according to the same scientific standards as conventional drugs. Packaging or marketing information does not need to be approved by the U.S. Food and Drug Administration (FDA) before a product reaches the market. The herbal therapy need only describe how the “structure and function” of the human body is affected and cannot be marketed for the diagnosis, treatment, cure or prevention of disease. No protection is offered against misleading or fraudulent claims. The American Academy of Pediatrics (AAP) Committee on Children with Disabilities has issued guidelines for discussing CAM use (specifically herbal therapies) with families (http://www.aap.org/healthtopics/complementarymedicine.cfm).

Accurate Clinical Research Data

Clinical data is often lacking for many herbal therapies. Because herbal therapies are considered dietary supplements and not drugs, premarket testing and studies on safety and efficacy are not required. More recently, studies of herbal therapies using sound investigational methodology are being published in peer-reviewed journals. This will undoubtedly assist in making informed decisions regarding the use of herbal therapies.

Herb–Drug Interactions

Clinicians should be aware of various herb–drug interactions (Table 83.2). One of the most significant such interactions is by agents that cause antiplatelet activity. Recent evidence shows serious interactions with St. John's wort and cyclosporine, oral contraceptives, and antiretroviral agents including indinavir. A number of herbal therapies when combined with warfarin (Coumadin) or nonsteroidal anti-inflammatory drugs have led to bleeding complications. Preoperative counseling on the risks of these herbal therapies should be provided to patients undergoing surgery. To ensure safety, discontinuation of these herbs at least 2 weeks before surgery should occur, until more data is available. At a minimum, frequent measurements of the prothrombin time and/or the international normalized ratio may be necessary to avoid complications.

Herb Toxicity

Herbal therapies have been known to cause toxicity to various organ systems (Table 83.3) including:

  1. Liver: The organ that appears to be the most common target of serious herbal toxicity is the liver. Two common types of liver insults are hepatitis and veno-occlusive disease. Chaparral has been implicated in acute hepatitis causing subacute hepatocellular necrosis leading to cholestatic hepatitis and eventually liver failure requiring transplantation. Additionally, germander has been thought to be involved in causing hepatotoxicity and fatality. Several Chinese herbal therapies have been found to cause liver toxicity includingJin Bu Huan, which contains the alkaloid levo-tetrahydropalmatine. This herbal therapy contains structural similarities to hepatotoxic pyrrolizidine alkaloids previously documented to cause liver damage. Clinically, exposure to this compound may lead to hepatomegaly and ascites caused by hepatic

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central vein dilation and fibrosis. In utero exposure has been linked with hepatic veno-occlusive disease and death in the newborn.

  1. Cardiotoxicity: Cardiotoxicity has been associated with ingestion of herbal therapies containing aconite alkaloids. These therapies are thought to activate sodium channels and have widespread effects on the excitable membranes of cardiac, neural, and muscle tissue. Enhancement of transmembrane inward currents induces automaticity. Fatal arrhythmias have been described in case reports.

Herbal therapies possess the potential for harm, although the widespread use to date has not led to large numbers of complications. This may be in part due to underreporting of herbal acute drug reactions and toxicities. Herbal therapies have the potential to add a great deal to the existing treatment options available to patients. Further study and long-term trials are needed to assess safety and efficacy.

TABLE 83.2
Selected Drug–Herb Interactions Important in Adolescent Health

Herbal Product

Drug or Drug Class

Potential Interaction

OCP, oral contraceptive pill; SSRI, selective serotonin reuptake inhibitor; TCA, tricyclic antidepressant.
Adapted from Drug-herb interactions. In: The review of natural products. St. Louis, MO: Facts and Comparisons, 1999, with permission.

Green tea

Warfarin

Decreased anticoagulant activity due to vitamin K content

Kava

Alprazolam

Additive or synergistic effects

St. John's wort

Cyclosporine

Significant metabolism through P-450 system may lead to decreased serum drug levels

 

Digoxin

 
 

OCP

 
 

Protease inhibitors

 
 

TCAs

 
 

Theophylline

 
 

Warfarin

 
 

Iron

May lead to decreased absorption or iron

 

SSRIs

May lead to increased side effects as well as the serotonin syndrome

 

Benzodiazepam

May reduce the effectiveness in reducing anxiety and may increase the risk of side effects such as drowsiness

 

Photosensitizing drugs (e.g. lansoprazole, omeprazole, piroxicam, and sulfonamide antibiotics)

Increased risk of sun sensitivity

Valerian

Barbiturates

Possible synergistic effects

 

Benzodiazepines

Increased sedation and increased side effects

Yohimbe

TCAs

Hypertension

Panax ginseng

Anticoagulants

Inhibition of platelet aggregation through inhibition of thromboxane synthetase, arachidonic acid production, inhibition of epinephrine, platelet thromboxane synthetase aggregation inhibition of platelet-activating factor

Garlic

   

Feverfew

   

Ginkgo

   

Panax ginseng

Oral hypoglycemics

Enhanced effects

Echinacea

Immunosuppressants

Interference with immunosuppression

Dosing Issues and Active Compounds

In traditional medicine, clinicians have become accustomed to using pharmaceutical agents that by definition possess the same strength and high quality. This is not always the case with herbal medicines. Because herbs represent complex entities containing hundreds of constituents, it is difficult to find one particular component representing the active agent. In many cases, particular herbal treatments have been evaluated with a focus on individual extracts and chemical entities such as Ginkgo biloba extract (EGb 761). Patients should be counseled on the use of a specific extract in an herbal product that has been clinically studied. If manufacturers have not produced an herbal product using a particular extract, this product should not be recommended.

Whether there is benefit to standardizing an herbal therapy to one identifiable component is a matter of current debate. According to some, the worthy goal of standardization—to achieve a consistent level of the main

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therapeutically effective active plant constituent—remains remote. Efforts to achieve this will require characterization, bioactivity assessment, and correlation with clinical end points. The standardization of phytomedicines serves as a precaution for the quality of medicinal plant extracts.

TABLE 83.3
Examples of Herbal Therapies Associated with Adverse Effects

Name

Responsible Ingredient

Adverse Effect

From Ernst E, Pittler MH. Herbal Medicine. Medical Clinics of North America 2002; 86(1): 149–161.

Aconite (Aconitum napellus)

Contains toxic alkaloids (aconitine)

Heart failure

Aristolochia species

Aristolochic acid is nephrotoxic and mutagenic

Renal failure

Celandine (Chelidonium majus)

Toxic alkaloids

Hemolytic anemia, hepatitis

Chamomile (Chamomilla recutita)

Sesquiterpene lactone

Potent skin sensitizer

Chaparral (Larrea tridentata)

Nordihydroguaiaretic acid

Hepatitis, renal carcinoma

Chaste tree (Vitex agnus-castus)

Estrogen-like substances

Hormonal effects

Comfrey (Symphytum officinale)

Pyrrolizidine alkaloids

Hepatitis

Ephedra species

Ephedrine

Heart problems, circulatory problems, death

Goldenseal (Hydrastis canadensis)

Isoquinoline alkaloids

Uterine contractions

Kelp (Fucus pyriferus)

Iodine

Hyperthyroidism

Licorice (Glycyrrhiza glabra)

Glycyrrhizin

Mineralocorticoid effects

Mistletoe (Viscum album)

Viscotoxins, lectins

Local irritation, allergic reactions

Senna (Cassia senna)

Anthranoid derivatives

Suspected mutagenicity

The dosage and length of treatment of various herbal therapies also remains controversial.

Long-term Use

Use of herbal therapies for extended periods of time presents a dilemma for the practicing clinician. Most studies involving herbal therapies do not evaluate long-term effects. Herbal therapies containing tannins have documented an increase risk of certain oropharyngeal cancers with long-term exposure. Additionally, several other herbals have been thought to possess components that may be carcinogenic over time. Herbal therapies should only be used on a time-limited basis until more data is available regarding long-term safety. Adolescents wishing to remain on herbal therapies should be monitored periodically for signs of toxicity and potential adverse effects. Ultimately, adolescents should be informed that the long-term effects of most herbal therapies are unknown. As such, close follow-up is recommended.

Contamination

A lack of quality control and regulation has resulted in contamination and misidentification of plant species (Table 83.4). Herbal therapies may be contaminated with heavy metals or bacteria/fungal organisms when being manufactured or stored. In one study, blood lead levels were significantly higher in children consuming Chinese herbal therapies compared to those who were not. Furthermore, fungal contamination has been noted to be a problem. In one report from Croatia, 62 samples of medicinal plant material and 11 samples of herbal tea were found to be contaminated with fungal elements. Patients and families should be advised to use products from reputable manufacturers, which use higher regulatory standards (e.g., European agencies such as German Commission E) to ensure the safe manufacturing of herbal therapies.

TABLE 83.4
Documented Contaminants/Adulterants Found in Herbal Therapies: Not All Inclusive

From Am J Med 1998;104:175, with permission.

Aluminum

Indomethacin

Arsenic

Lead

Aspirin

Mercury

Cadmium

Theophylline

Caffeine

Thiazide diuretics

Corticosteroids

Zinc

Diazepam

 

Use in Pregnancy and Lactation

Women contemplating pregnancy, currently pregnant, or nursing should not use herbal therapies, given the lack of evidence on safety.

Consultation

Adolescents and their families who wish to use herbal therapies may seek the advice of a naturopath, herbalist, or traditional Chinese medicine practitioner. Information

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on these practitioners is available through their respective licensing organizations.

Common Herbal Therapies in the Adolescent Population

Among adolescents, it is quite common to find the use of herbal therapies for a number of conditions—weight loss, depression and anxiety, upper respiratory tract infections, and the enhancement of athletic performance. A brief review on commonly used herbal therapies is outlined in the following text.

Psychoactive Herbal Therapies

St. John's Wort

Uses

Historically, St. John's wort has been used for depression and wound healing.

Mechanism of Action

The two active ingredients are hypericin and hyperforin, which inhibit the reuptake of serotonin, norepinephrine, and dopamine. Various studies have noted monoamine oxidase inhibition in vitro along with modulation of melatonin secretion.

Clinical Studies

Several studies comparing St. John's wort to tricyclic antidepressants (TCAs) in patients with mild depression, have found that St. John's wort was superior to placebo and as effective as low-dose TCAs. More recently, several studies comparing St. John's wort to selective serotonin reuptake inhibitors (SSRIs) found comparable efficacy using high doses of St. John's wort and low doses of SSRIs. This has not been confirmed in the treatment of major depression.

Side Effects

St. John's wort has been noted to have a low incidence of side effects including GI symptoms, dizziness, and confusion. Phototoxicity may occur with ingestion of high doses. Although this is rare, it resolves with the discontinuation of the herb.

Drug Interactions

St. John's wort has been shown to induce the cytochrome P-450 metabolic pathway. Studies have shown a significant interaction with St. John's wort and cyclosporine, oral anticoagulants, oral contraceptives, and certain antiretroviral agents including indinavir. The concomitant use of St. John's wort with standard antidepressants is also contraindicated because of the risk of serotonin syndrome.

Kava

Uses

Historically, kava was an important cultural entity in the South Pacific, particularly in the Fiji Islands where it is used as a ceremonial drink. It was also used for its calming effects. More recently, it has been used as a natural alternative to sedatives and anxiolytics.

Mechanism of Action

It is thought to work by inhibiting γ-aminobutyric acid (GABA) receptor binding.

Clinical Studies

In a number of small studies, kava was found to reduce the scores on anxiety scales when compared with the scores of those taking a placebo. Kava was effective as a standard anxiolytic.

Side Effects

Heavy kava drinkers acquire yellowing and flaking of the skin, known as kava dermopathy. This resolves with discontinuation of the herb. There is a potential risk of severe liver injury associated with the use of kava-containing dietary supplements. There are several reports of extrapyramidal-like dystonic reactions with kava use.

Drug Interactions

Combined use of sedatives and alcohol should be avoided as it has been reported to cause oversedation.

Valerian Root

Uses

Valerian root has been used for centuries as a sedative agent and sleep aid. Recently, it has been used as an aid for insomnia and jet lag. It is also used for migraine headaches, fatigue, and intestinal cramps.

Mechanism of Action

Valerian root has effects on GABA receptors, leading to its sedative effects.

Clinical Studies

Several human trials confirm a mild sedative effect. Few studies exist regarding the anxiolytic effects of valerian root in vivo.

Side Effects

Headache, excitability, uneasiness, and cardiac disturbances.

Drug Interactions

Care should be exercised when combining valerian root with other sedative agents and alcohol.

Chamomile

Uses

Historically, chamomile has been used for GI discomfort, peptic ulcer disease, pediatric colic, and mild anxiety.

Mechanism of Action

Chamomile may act by binding to central benzodiazepine receptors.

Clinical Studies

Several small trials on humans have noted chamomile to have hypnotic–sedative properties. However, none of these trials have been randomized or controlled.

Side Effects

The FDA regards chamomile as safe when used as a spice, seasoning, or flavoring agent. Although several cases of significant allergic reactions to chamomile have been reported, no significant toxicity has been reported.

Drug Interactions

No drug–herb interactions have been noted.

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Herbs for Weight Loss

Ma Huang (Ephedra)

Uses

Ephedra, also known by its Chinese name Ma Huang, is a naturally occurring substance derived from plants. Its principal active ingredient is ephedrine. Ephedra products have been used to aid weight loss, enhance sports performance, and increase energy. In 2004, the FDA banned the sale of dietary supplements containing ephedra owing to reported serious adverse effects.

Mechanism of Action

Ephedra acts by increasing the levels of norepinephrine, epinephrine, and dopamine, and by stimulating both α and β adrenoreceptors. This leads to anorectic and thermogenic effects by increasing metabolism. The addition of caffeine to ephedra appears to blunt the negative feedback control on the release of norepinephrine. The combination of adrenergic and dopaminergic effects leads to heightened alertness, decreased fatigue, and a lessened desire for sleep. At higher doses, the release of norepinephrine causes anxiety, restlessness, and insomnia.

Clinical Studies

In a meta-analysis of 52 controlled trials and 65 case reports, ephedrine and ephedra were shown to promote modest short-term weight loss (≈0.9 kg/month compared to placebo) (Shekelle, 2003).

Side Effects

It is well known that Ma Huang has the potential to cause serious side effects that have led to a number of reported deaths. On the basis of known side effects and minimal benefit, this product should not be recommended for use. The combination of caffeine and ephedra has an increased risk of psychiatric symptoms, such as euphoria, neurotic behavior, agitation, depressed mood, giddiness, irritability, and anxiety. Other side effects may include increased blood pressure, palpitations, tachycardia, chest pain, coronary vasospasm, and even cardiomyopathy. The structural similarity of ephedrine to amphetamine raises concern about possible abuse.

Guaraná (Paullinia cupana, P. crysan, P. sorbilis)

Uses

Guaraná is a small shrub native to Venezuela and northern Brazil, known for the high stimulant content of the fruit. Guaraná contains a caffeine-like product guaranine, along with theobromine, theophylline, xanthine, and other xanthine derivatives and acts as a stimulant. A number of energy drinks containing guaraná are available.

Mechanism of Action

The applicable part of guaraná is the seed. Guaraná contains 3.6% to 5.8% caffeine (compared to 1%–2% in coffee). Caffeine is responsible for the pharmacological effects of guaraná.

Clinical Studies

One study of overweight adults reported that the combination of yerba mate (leaves of Ilex paraguayensis), guaraná (seeds of Paullinia cupana), and damiana significantly delayed gastric emptying, causing prolonged perceived gastric fullness with an associated weight loss over 45 days (Andersen, 2001).

Side Effects

Similar to those of ephedra and caffeine.

Hydroxycitric Acid (Garcinia Cambogia)

Uses

Garcinia is marketed as an herbal weight-loss product.

Mechanism of Action

It is thought that hydroxycitric acid can increase fat oxidation by inhibiting citrate lyase, an enzyme that plays a crucial role in energy metabolism during de novo lipogenesis.

Clinical Studies

Several clinical trials have shown no benefit of this herbal compared to placebo.

Side Effects

Minor side effects have been reported. Higher doses have caused abdominal pain and vomiting.

Hoodia Gordonii

Uses

Hoodia gordonii looks like a cactus, but it is a succulent from the Kalahari Desert in southern Africa. Bushmen from the area have been using hoodia for centuries to help ward off hunger during long trips in the desert.

Mechanism of Action

A steroidal glycoside termed P57AS3 (P57) has been isolated from hoodia gordonii and may increase the content of adenosine triphosphate (ATP) causing a decrease in hunger.

Clinical Studies

Preliminary data suggests that overweight men who consume P57 have significantly lower calorie intake than those taking a placebo.

Side Effects

None reported.

Herbal Therapies for Sports Enhancement

Ginseng (Panax Ginseng)

Uses

Ginseng has been used for >2,000 years to strengthen both mental and physical capacity. Recently, ginseng has become popular as an “adaptogenic” (stress-protective) agent.

Mechanism of Action

Ginseng is thought to have effects on nitric oxide synthesis in endothelial tissue of lung, heart, and kidney. In addition, effects on serotonin and dopamine may also be responsible for its actions. Other effects may be related to activity on the hypothalamic–pituitary–adrenal system.

Clinical Studies

To date, seven trials investigating ginseng's effects on physical performance in young, active volunteers during cycle ergometer exercises have been reported. Four studies found no significant difference between ginseng and placebo, whereas three studies found a significant decrease in heart rate and increase in maximal oxygen uptake with ginseng.

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Side Effects

Adverse effects may include nervousness, insomnia, and GI disturbance associated with prolonged use. Because of the estrogen-like effect, ginseng has been reported to cause mastalgia and vaginal bleeding in women.

Drug Interactions

Ginseng may interact with oral anticoagulants, antiplatelet agents, corticosteroids, and hypoglycemic agents.

Miscellaneous Herbal Therapies

Echinacea

Uses

Echinacea (E. angustifola, E. pallida, E. purpurea) has been used for centuries by Native Americans for aches and colds. It has also been used as a topical analgesic for snake bites, stings, and burns. It has become extremely popular as a natural immune booster.

Mechanism of Action

Echinacea works by protecting the integrity of the hyaluronic acid matrix and by stimulating the alternate complement pathway. It also promotes nonspecific T-cell activation by binding to T cells and increasing interferon production. The polysaccharides arabinogalactan and echinacin are the active ingredients of Echinacea and are felt to have immune-modulating effects on the body. Other ingredients include glycosides, alkaloids, alkylamides, polyacetylenes, and fatty acids that are believed to inhibit viral replication, improve the motility of polymorphonuclear cells, and enhance phagocytosis. Echinacea may also enhance natural killer cell activity.

Clinical Studies

In a Cochrane review, Echinacea preparations were found to be better than placebo for the treatment of upper respiratory symptoms, but no better than placebo for the prevention of the common cold (Linde, 2006).

Side Effects

Adverse effects are usually mild and may include skin rash, GI upset, and diarrhea. Patients with progressive systemic diseases such as multiple sclerosis, tuberculosis, systemic lupus erythematosus, autoimmune diseases, and human immunodeficiency virus infection should not use Echinacea because of its possible effects on the immune system.

Drug Interactions

Echinacea should not be used in patients who are immunosuppressed or in those who are on immunosuppressant medications.

Feverfew

Uses

Feverfew has become a very popular herbal therapy for the prevention and treatment of migraine headaches. Historically, it has been used for URI, melancholy, and GI distress.

Mechanism of Action

Feverfew is thought to inhibit prostaglandin, thromboxane, and leukotriene synthesis. It also reduces serotonin release from thrombocytes and polymorphonuclear leukocytes. The mechanism of action for preventing migraine headaches is unknown.

Clinical Studies

Two randomized trials have shown benefit of feverfew use for the prevention of migraines. However, these studies did not address acute treatment of migraines.

Side Effects

Adverse effects include occasional mouth ulcerations, contact dermatitis, dizziness, diarrhea, and heartburn.

Drug Interactions

Feverfew may interact with anticoagulants and antiplatelet agents because of its platelet aggregation inhibition.

Garlic

Uses

Garlic has long been used as a medicinal agent to increase physical strength and as a topical antiseptic. In recent years, it has been used as a natural cholesterol-lowering agent.

Mechanism of Action

Garlic causes a reduction in cholesterol synthesis by reducing the hepatic activity of β-hydroxy-β-methylglutaryl-CoA (HMG-CoA) reductase, an enzyme essential to cholesterol biosynthesis.

Clinical Studies

A number of small studies have noted a modest reduction in the total cholesterol level when compared to placebo. Other studies have found no reduction in cholesterol. The negative findings may be due to the preparation lacking the active ingredients in fresh garlic.

Side Effects

Garlic is generally considered safe although, may cause some GI distress including gas symptoms and skin irritation.

Drug Interactions

Garlic has some antiplatelet activity and therefore should not be used in patients on anticoagulant medication.

Adverse events associated with kava and all other herbal therapies should be reported as soon as possible to FDA's MedWatch program by calling their toll-free number (1-800-332-1088) or through the Internet (http://www.fda.gov/medwatch).

Acupuncture

Overview

Acupuncture is widely used in children and adults. In 1991, an estimated $14 billion out-of-pocket expenses were used for acupuncture therapy. Data from family practice physicians and internists have shown that it is one of the most frequently recommended CAM therapies.

Theory

Originating in China >2,000 years ago, acupuncture is an ancient Chinese therapeutic treatment based on the premise that energy (Qi,Chi) flows through the body along channels known as meridians, connected by acupuncture points. The flow of Qi is manipulated by insertion of fine needles

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at acupuncture points along the involved meridians. Since the 1600s, acupuncture has been practiced in European cultures. In 1916, Sir William Osler recommended acupuncture for the treatment of pain. There has been increased use of acupuncture in the United States during the 20th century due in part to the writings of a New York Times editor whose postoperative pain was managed with this treatment.

In assessing a patient, an acupuncturist takes a history and then performs an examination, which includes the determination of the shape, color, and coating of the tongue and the force, flow, and character of the radial pulse. The specific treatment is based on the diagnosis and may include solid sterile needle placement, moxibustion (the practice of burning dried herbs over the acupuncture needles), acupressure, or cupping.

The flow of Qi through acupuncture points is difficult to translate into typical Western biomedical theory. There is segmental inhibition of pain impulses at the local site of needle stimulation that is carried in the slower unmyelinated C fibers and sensory A-δ fibers. Opioid peptides and other neurotransmitters are released, and naloxone has been shown to reverse the analgesic effects of acupuncture. Acupuncture may also stimulate the hypothalamus and pituitary glands and may modify neurotransmitter secretion.

Evidence of Health Benefits

  • Dental pain
  • Postoperative nausea and vomiting
  • Chemotherapy nausea and vomiting

Possible Health Benefits

  • Migraine/tension headaches
  • Back pain
  • Dysmenorrhea
  • Acute and chronic pain
  • Substance abuse

Complications

  • Pneumothorax, angina, septic sacroiliitis, and epidural and temporomandibular abscess

Yoga

Yoga is widely known for helping to build strength and flexibility through a combination of meditation, controlled breathing, and stretches. Research has explored yoga's potential value as an adjunct treatment for such health problems as anxiety, hypertension, heart disease, depression, low-back pain, headaches, and cancer. More studies are needed to evaluate the efficacy of this intervention.

Massage

Overview

Consumers in the United States spend two to four billion dollars annually on 75 million visits to massage therapists. More than 150,000 trained massage therapists practice in the United States.

Theory

Massage therapy is thought to release muscle tension, remove toxic metabolites, and facilitate oxygen transport to cells and tissues. Of the five forms of massage therapy, the most common is traditional European or Swedish. Swedish massage is performed on a special massage table or chair. The focus is to relax the muscles and improve circulation. Deep-muscle or deep-tissue massage technique is commonly used in sports. Structural massage and movement integration also called bodywork utilizes deep-tissue massage to correct posture problems and movement imbalances. Chinese healers may perform acupressure and shiatsu, known as the Oriental method. Reflexology is an energy form of massage where the focus is primarily on the hands, feet and ears.

Evidence of Health Benefits

  • Preterm infants have shortened hospital stays
  • Improved glucose control in type 1 and 2 diabetes mellitus
  • Decreased pain in juvenile rheumatoid arthritis

Possible Health Benefits

  • Less need for topical steroids in atopic dermatitis
  • Improved pulmonary function in patients with cystic fibrosis
  • Decreased anxiety in eating disorders
  • Improved mood in depression
  • Improved control in asthma

Complications

  • None reported

Chiropractic

Overview

Doctors of Chiropractic (DCs) are the most frequently visited CAM providers. Chiropractors treat many conditions including low-back pain, cervical pain, headache, otitis media, dysmenorrhea, and carpal tunnel syndrome. In one study, 70% of the visits to a chiropractor were for back and neck problems. In 1993, 20 million children and adolescents in the United States were seen by chiropractors for respiratory problems (including asthma); ear, nose, and throat problems; colic; enuresis; allergies and general preventative care.

Theory

Chiropractic, founded by Daniel David Palmer, is based on the theory that all disease can be traced to malpositioned bones in the spinal column called subluxations, which lead to the entrapment of spinal nerves. Subluxations produce symptoms of disease because optimal functioning of tissues and organs are not allowed. Physical adjustment of the

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spine restores proper alignment of the spine by relieving nerve entrapments. For example, many DCs believe that improper eustachian tube drainage associated with acute or chronic otitis media is caused by atlantooccipital joint misalignment.

There are two theories underlying the practice of chiropractic medicine. The International Chiropractic Association (ICA) focuses on the use of chiropractic adjustments for health promotion. Vertebral subluxations are thought to disrupt spinal nerves, which can result in a variety of problems with function. By correcting the subluxations, the bodies' self-healing powers may lead to optimal health. This organization is known for its advancement of pediatric chiropractic care and its opposition to mandatory immunizations and comprises 5% to10% of all DCs in the United States. The American Chiropractic Association (ACA) uses a wide range of diagnostic tools including laboratory tests and advanced imaging (magnetic resonance imaging and computed tomography). They also support nutritional supplements and herbal remedies as treatment options.

Evidence of Health Benefits

  • Decreased pain in acute low-back pain

Possible Health Benefits

  • Improvement in symptoms of acute otitis media

Not effective

  • Asthma

Complications

  • Stroke, myelopathies, and radiculopathies after cervical manipulation
  • Adverse outcomes are most likely to occur with bleeding dyscrasia, when improper diagnosis is made in the presence of a herniated disc or when an improper manipulative method is utilized

Homeopathic Medicine

Overview

Homeopathy is a medical discipline first promoted in the late 18th century by Samuel Hahnemann (1755–1843). In 1990, there were approximately 5 million visits to homeopathic providers in the United States. Homeopathic medicine sales increased from $100 million in 1988 to $250 million in 1996. In some European countries, up to 40% of physicians use homeopathy in their practice.

Theory

Three concepts embody the philosophy of homeopathic medicine: (a) finding the similum or similar substance, (b) treating the totality of symptoms, and (c) using the minimum dose through potentization.

The “principle of similars” is that highly dilute preparations of substances causing specific symptoms in healthy volunteers are reported to stimulate healing in ill patients who have similar symptoms.

The preparation of homeopathic remedies requires serial dilution and succussion (shaking). A “30C potency” is a remedy that has been diluted by a factor of 1:100 thirty successive times. There are several theories for the mechanism of action of these highly dilute substances. The “memory of water” theory is basic to homeopathy, and holds that water is capable of containing “memory” of particles dissolved in it. This memory allows water to retain the properties of the original solute even when there is no solute left in the solution. In other words, the curative power of the remedy is engrafted into the water molecules and the water retains a “memory” of these changes.

Homeopathy is one of the most controversial of the CAM therapies. Many health care providers remain suspicious that infinitesimally diluted substances retain their biological effects. As a result, many question the effectiveness of this intervention. Others believe that homeopathic remedies are a permissible approach for many medical problems.

Research Evidence

Anecdotal support of the efficacy of homeopathy has been replaced with more scientific evidence. In a meta-analysis of 32 trials in adults, individualized homeopathy was significantly more effective than placebo in treating symptomatic seasonal allergies and postoperative ileus among other complaints. However, when the analysis was restricted to the methodologically sound trials, no significant effect was seen. A second meta-analysis of 110 trials of homeopathy and 110 matched conventional medicine trials for respiratory tract infections, gynecological problems, and musculoskeletal disorders demonstrated weak evidence for specific effects of homeopathic remedies.

Possible Health Benefits

  • Recurrent upper respiratory tract infections
  • Otitis media
  • Attention-deficit disorder

Complications

  • Aggravation of symptoms
  • Contamination of remedy

In conclusion, clinicians need to understand and appreciate the variety of health care options available to adolescents and their families. Open, honest, and nonjudgmental discussions with adolescents using or planning to use CAM will bring about a safe and rational use of these treatments for which there is evidence of efficacy, and enable adolescents to make informed choices. Improved communication can be addressed by following the recommendations outlined in Table 83.5. Health care providers need to inquire regularly about CAM use because such insight will help clinicians provide better care to adolescents.

TABLE 83.5
Talking with Your Patients about Complementary and Alternative Medicine

CAM, complementary and alternative medicine.
Breuner CC. Complementary medicine in pediatrics: a review of acupuncture, homeopathy, massage and chiropractic therapies.Current Probs in Pediatric and Adolescent Health Care. 2002;32(10):347–384.

Be open-minded. Most patients are reluctant to share information about their use of CAM therapies because they are concerned their physicians will disapprove. By remaining open-minded, you can learn a lot about your patients' use of unconventional therapies. These strategies will help foster open communication.

Ask the question. I recommend asking every patient about his or her use of alternative therapies during routine history taking. One approach is simply to inquire, “Are you doing anything else for this condition?” It's an open-ended question that gives the patient the opportunity to tell you about his or her use of other health care providers or therapies. Another approach is to ask, “Are you taking any over-the-counter remedies such as vitamins or herbs?”

Avoid using the words “alternative therapy,” at least initially. This will help you to avoid appearing judgmental or biased.

Don't dismiss any therapy as a placebo. If a patient tells you about a therapy that you are unaware of, make a note of it in the patient's record and schedule a follow-up visit after you have learned more—when you'll be in a better position to negotiate the patient's care. If you determine the therapy might be harmful, you'll have to ask the patient to stop using it. If it isn't harmful and the patient feels better using it, you may want to consider incorporating the therapy into your care plan.

Discuss providers as well as therapies. Another way to help your patients negotiate the maze of alternative therapies is by stressing that they see appropriately trained and licensed providers and knowing whom to refer to in your area. Encourage your patients to ask alternative providers about their background and training and the treatment modalities they use. By doing so, your patients will be better equipped to make educated decisions about their health care.

Discuss CAM therapies with your patients at every visit. Charting the details of their use will remind you to raise the issue. It may also help alert you to potential complications before they occur.

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Web Sites

General

http://www.nccam.nih.gov. National Center for Complementary and Alternative Medicine.

http://www.amfoundation.org. Alternative Medicine Foundation.

Herbal Medicine

http://www.herbmed.org. HerbMed database.

http://www.herbs.org. Herb Research Foundation.

http://www.herbalgram.org. American Botanical Council.

http://www.naturaldatabase.com. Natural Medicines Comprehensive Database.

Mind Body Medicine

http://www.umassmed.edu/cfm/clinical.cfm. The Stress Reduction Clinic at the University of Massachusetts.

http://www.holisticmedicine.org. The American Holistic Medical Association.

http://www.ahha.org. The American Holistic Health Association.

http://www.nicabm.com. The National Institute for Clinical Applications of Behavioral Medicine.

http://www.cmbm.org. The Center for Mind Body Medicine.

Yoga

http://www.americanyogaassociation.org/.

Acupuncture

http://www.aaom.org. American Association of Oriental Medicine.

http://www.acuall.org. Acupuncture and Oriental Medical Alliance.

http://www.medicalacupuncture.org. American Academy of Medical Acupuncture.

Chiropractic

http://www.amerchiro.org. American Chiropractic Association.

http://www.chiropractic.org. International Chiropractors Association.

Homeopathy

http://www.homeopathic.org. National Center for Homeopathy.

Massage

http://www.amtamassage.org. American Massage Therapy Association.

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http://www.ncbtmb.com. National Certification Board for Massage Therapy and Bodywork.

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