Cora Collette Breuner
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
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.
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:
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
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.
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).
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.
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.
Herbal therapies have been known to cause toxicity to various organ systems (Table 83.3) including:
central vein dilation and fibrosis. In utero exposure has been linked with hepatic veno-occlusive disease and death in the newborn.
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.
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
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.
The dosage and length of treatment of various herbal therapies also remains controversial.
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.
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.
Use in Pregnancy and Lactation
Women contemplating pregnancy, currently pregnant, or nursing should not use herbal therapies, given the lack of evidence on safety.
Adolescents and their families who wish to use herbal therapies may seek the advice of a naturopath, herbalist, or traditional Chinese medicine practitioner. Information
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
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.
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.
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.
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.
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.
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.
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.
Combined use of sedatives and alcohol should be avoided as it has been reported to cause oversedation.
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.
Several human trials confirm a mild sedative effect. Few studies exist regarding the anxiolytic effects of valerian root in vivo.
Headache, excitability, uneasiness, and cardiac disturbances.
Care should be exercised when combining valerian root with other sedative agents and alcohol.
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.
Several small trials on humans have noted chamomile to have hypnotic–sedative properties. However, none of these trials have been randomized or controlled.
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.
No drug–herb interactions have been noted.
Herbs for Weight Loss
Ma Huang (Ephedra)
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.
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).
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)
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.
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).
Similar to those of ephedra and caffeine.
Hydroxycitric Acid (Garcinia Cambogia)
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.
Several clinical trials have shown no benefit of this herbal compared to placebo.
Minor side effects have been reported. Higher doses have caused abdominal pain and vomiting.
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.
Preliminary data suggests that overweight men who consume P57 have significantly lower calorie intake than those taking a placebo.
Herbal Therapies for Sports Enhancement
Ginseng (Panax Ginseng)
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.
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.
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.
Ginseng may interact with oral anticoagulants, antiplatelet agents, corticosteroids, and hypoglycemic agents.
Miscellaneous Herbal Therapies
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.
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).
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.
Echinacea should not be used in patients who are immunosuppressed or in those who are on immunosuppressant medications.
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.
Two randomized trials have shown benefit of feverfew use for the prevention of migraines. However, these studies did not address acute treatment of migraines.
Adverse effects include occasional mouth ulcerations, contact dermatitis, dizziness, diarrhea, and heartburn.
Feverfew may interact with anticoagulants and antiplatelet agents because of its platelet aggregation inhibition.
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.
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.
Garlic is generally considered safe although, may cause some GI distress including gas symptoms and skin irritation.
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 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.
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
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
Possible Health Benefits
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.
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.
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
Possible Health Benefits
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.
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
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
Possible Health Benefits
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.
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.
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
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.
http://www.nccam.nih.gov. National Center for Complementary and Alternative Medicine.
http://www.amfoundation.org. Alternative Medicine Foundation.
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.
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.
http://www.amerchiro.org. American Chiropractic Association.
http://www.chiropractic.org. International Chiropractors Association.
http://www.homeopathic.org. National Center for Homeopathy.
http://www.amtamassage.org. American Massage Therapy Association.
http://www.ncbtmb.com. National Certification Board for Massage Therapy and Bodywork.
References and Additional Readings
Abuaisha BB, Costanzi JB, Boulton AJ. Acupuncture for the treatment of chronic painful peripheral neuropathy. Diabetes Res Clin Pract 1998;39:115.
Adoga GI. The mechanism of the hypolipidemic effect of garlic oil extract in rats fed on high sucrose and alcohol diets. Biochem Biophys Res Commun 1987;142:1046.
Almeida JC, Grimsley EW. Coma from the health food store: interaction between kava and alprazolam. Ann Intern Med 1996;125:940.
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. Reaffirmed in Pediatrics. 2005;115:1438.
Andersen T, Fogh J. Weight loss and delayed gastric emptying following a South American herbal preparation in overweight patients. J Hum Nutr Diet 2001;14(3):243.
Angell M, Kassirer JP. Alternative medicine—the risks of untested and unregulated remedies. N Engl J Med 1998;339(12):839.
Arnold LE. Alternative treatments for adults with attention-deficit hyperactivity disorder (ADHD). Ann N Y Acad Sci 2001;931:310.
Assendeff W, Bouter L, Knipschild P. Complications of spinal manipulation: a comprehensive review of the literature. J Fam Pract 1996;42:475.
Awang DVC, Kindack DG. Herbal medicine: Echinacea. Can Pharm J 1991;124:512.
Baischer W. Acupuncture in migraine. Long-term outcome and predicting factors. Headache 1995;35:472.
Balon J, Aker PD, Crowther ER, et al. A comparison of active and simulated chiropractic manipulation as adjunctive treatment for childhood asthma. N Eng J Med1998;339(15):1013.
Barnett ED, Levatin JL, Chapman EH, et al. Challenges of evaluating homeopathic treatment of acute otitis media. Pediatr Infect Dis J 2000;19:273.
Barron RL, Vanscoy GJ. Natural products and the athlete: facts and folklore. Ann Pharmacother 1993;27:607.
Batchelor WB, Heathcote J, Wanlesa IR. Chaparral induced hepatic injury. Am J Gastroenterol 1996;90:831.
Bent S, Ko R. Commonly used herbal medicines the Unites States: a review. Am J Med 2004;116:478.
Bergmann T, Peterson D, Lawrence D. Chiropractic technique: principles and procedures. New York, NY: Churchill Living-stone, 1993:747.
Berkowitz CD. Homeopathy: keeping an open mind. Lancet 1994;344:701.
Berthold HK, Sudhop T, von Bergmann K. Effect of a garlic oil preparation on serum lipoproteins and cholesterol metabolism: a randomized controlled trial. JAMA 1998;279:1900.
Blumenthal M. Herb sales down 3% in mass market retail stores—sales in natural food stores still growing, but at lower rate. HerbalGram 2000;49:68.
Blumenthal M, Busse W, Goldberg A, et al. The complete German Commission E monographs: therapeutic guide to herbal medicines. Austin, TX: American Botanical Council, 2000.
Braun CA, Bearinger LH, Halcon LL, et al. Adolescent use of complementary therapies. J Adolesc Health 2005;37(1):76.
Brevoort P. The booming U.S. botanical market: a new overview. HerbalGram 1998;44:33.
Breuner CC. Complementary medicine in pediatrics: a review of acupuncture, homeopathy, massage and chiropractic therapies. Curr Probl Pediatr Adolesc Health Care2002;32(10):347.
Breuner CC, Barry P, Kemper KJ. Alternative medicine use by homeless youth. Arch Pediatr Adolesc Med 1998;152(11):1071.
Brewington V, Smith M, Lipton D. Acupuncture and detoxification treatment: an analysis of controlled research. J Subst Abuse Treat 1994;11:289.
Brumbaugh AG. Acupuncture new perspectives in chemical dependency treatment. J Subst Abuse Treat 1993;10:35.
Bullock ML. Controlled trial of acupuncture for severe recidivist alcoholism. Lancet 1989;1(8652):1435.
Canadian Pediatric Society. Children and natural health products; what every clinician should know. Paediatr Child Health 2005:10(4):227.
Carey TS, Garrett J, Jackman A, et al. The outcomes and costs of care for acute low back pain among patients seen by primary care practitioners, chiropractors, and orthopedic surgeons. The North Carolina back pain project. N Engl J Med 1995;333(14):913.
Cirigliano MD, Sun A. Advising patients about herbal therapies. JAMA 1998;280:1565.
Cohen MH, Kemper KJ. Complementary therapies in pediatrics: a legal perspective. Pediatrics 2005;115(3):774.
Cohen MH, Hrbek A, Davis RB, et al. Emerging credentialing practices, malpractice liability policies and guidelines governing complementary and alternative medical practices and dietary supplement recommendations. Arch Intern Med 2005;165:289.
Colson CRD, Debroe ME. Kidney injury from alternative medicine. Adv Chronic Kidney Dis 2005;12(3):261.
Committee on the Use of Complementary and Alternative Medicine by the American Public, Board on Health promotion and Disease Prevention, Institute of Medicine of the National Academies. Complementary and alternative medicine in the United States. Washington, DC: The National Academies Press, 2005.
Coulter ID. Patients using chiropractors in North America: who are they, and why are they in chiropractic care?. Spine 2002;27(3):291.
Day AS, Whitten KE, Bohane TD. Use of complementary and alternative medicines by children and adolescents with inflammatory bowel disease. J Paediatr Child Health2004;40:681.
DeLange de Klerk ESM, Blommers J, Kuik DJ, et al. Effect of homeopathic remedies medicines on daily burdens of symptoms in children with recurrent upper respiratory infections. Brit Med J 1994;309.
Diehl DL, Kaplan G, Coulter I, et al. Use of acupuncture by American physicians. J Altern Complement Med 1997;3:119.
Durant CL, Verhoef MJ. Chiropractic treatment of patients under 18 years of age. Fact. Focus Altern Complement Ther 1998;2(4):198.
Eisenberg DM. Advising patients who seek alternative medical therapies. Ann Intern Med 1997;127(1):61.
Eisenberg DM, Davis RB, Ettner SL, et al. Trends in alternative medicine use in the United States, 1990–1997. JAMA 1998;280:1569.
Eisenberg DM, Kessler RC, Foster C, et al. Unconventional medicine in the United States. N Engl J Med 1993;328:246.
Ernst, E. Adverse effects of spinal manipulation. In: Jonas WB, Levin JS, eds. Essentials of complementary and alternative medicine. Philadelphia: Lippincott Williams & Wilkins, 1999: 176.
Ernst E. Prospective studies of the safety of acupuncture: a systematic review. Am J Med 2001;110(6):481.
Ernst E, Kaptchuck TJ. Homeopathy revisited. Arch Int Neurol 1996;156:2162.
Ernst E, Pittler MH. Herbal Medicine. Med Clin North Am 2002;86(1):149.
Fearon J. A reflective overview of complementary therapies for children 1995–2005. Complement Ther Clin Pract 2005;11(1):32.
Field T. Massage and relaxation therapies' effects on depressed adolescent mothers. Adolescence 1996;31(124):903.
Field T, Morrow C, Valdeon C, et al. Massage reduces anxiety in child and adolescent psychiatric patients. Am Acad Child Adolesc Psychiatry 1992;31:125.
Field T, Quintino O, Hernandez-Reif M, et al. Adolescents with attention deficit hyperactivity disorder benefit from massage therapy. Adolescence 1998;333:103.
Field T, Schanberg S, Kuhn C, et al. Bulimic adolescents benefit from massage therapy. Adolescence 1998;33:555.
Firenzuoli F, Gori L. Garcinia cambogia for weight loss. JAMA 1999;282:234.
Fugh-Berman A. Herb-drug interactions. Lancet 2000;355:134.
Gardiner P, Kemper KJ. Herbs in pediatric and adolescent medicine. Pediatr Rev 2000;21(2):44.
Gillis CN. Panax ginseng pharmacology: a nitric oxide link? Biochem Pharmacol 1997;54:1.
Goldberg H. Feverfew for prevention of migraine. Altern Med Alert 1999;2(4):41.
Goldhaber-Fiebert S, Kemper K. Echinacea. The Longwood Herbal Task Force, 1999.
Halt M. Moulds and mycotoxins in herb tea and medicinal plants. Eur J Epidemiol 1998;14:269.
Heymsfield SB, Allison DB, Vasselli JR, et al. Garcinia cambogia (hydroxycitric acid) as a potential antiobesity agent: a randomized controlled trial. JAMA 1998;280:1596.
Hobbs C. Echinacea, a literature review: botany, history, chemistry, pharmacology, toxicology, and clinical uses. HerbalGram 1994;30:33.
Hondras MA, Linde K, Jones AP. Manual therapy for asthma. Cochrane Database Syst Rev 2005;3.
Hopkins MP, Androff L, Benninghoff AS. Ginseng face cream and unexplained vaginal bleeding. Am J Obstet Gynecol 1988;159:1121.
Hypericum depression trial study group. Effect of Hypericum perforatum (St. John's wort) in major depressive disorder: a randomized controlled trial. JAMA 2002;287:1807.
Izzo AA, Ernst E. Interactions between herbal medicines and prescribed drugs: a systematic review. Drugs 2001;61:2163.
Jussofie A, Schmiz A, Hiemke C. Kavapyrone-enriched extract from Piper methysticum as modulator of the GABA binding site in different regions of rat brain. Psychopharmacology1994;116:469.
Kaptchuk T. The web that has no weaver. New York: Congdon and Weed, 1983.
Kaptchuk TJ, Eisenberg DM. Chiropractic: origins, controversies and contributions. Arch Inter Med 1998;158:2215.
Katz M, Saibil F. Herbal hepatitis: subacute hepatic necrosis secondary to chaparral leaf. J Clin Gastroenterol 1990;12:831.
Kaufman DW, Kelly JP, Rosenberg L, et al. Recent patterns of medication use in the ambulatory adult population of the United States. JAMA 2002;287:337.
Kelly JP, Kaufman DW, Kelley K, et al. Recent trends in use of herbal and other natural products. Arch Intern Med 2005;165:281.
Kinzler E. Effect of a special kava extract in patients with anxiety, tension, and excitation states of nonpsychotic genesis. Arzneimittelforsch 1991;41:584.
Kriketos AD, Thompson HR, Greene H, et al. Hydroxycitric acid does not affect energy expenditure and substrate oxidation in adult males in a post absorptive state. Int J Obes Relat Metab Discord 1999;23:867.
Lamont J. Homeopathic treatment of attention deficit disorder. Br Homoeopath J 1997;86:196.
Lee KP, Carlini WG, McCormick GF, et al. Neurologic complications following chiropractic manipulation: a survey of California neurologists. Neurology 1995;45:1213.
Lee ACC, Li DH, Kemper KJ. Chiropractic care for children. Arch Pediatr Adolesc Med 2000;154:401.
Lindahl O, Lindwell L. Double-blind study of a valerian preparation. Pharmacol Biochem Behav 1989;32:1065.
Linde K, Barrett B, Wolkart K, Bauer R, Melchart D. Echinacea for preventing and treating the common cold. Cochrane Database Syst Rev. 2006; Jan 25:(1):CD000530.
Linde K, Clausius N, Ramirez G, et al. Are the clinical effects of homeopathy placebo effects; a meta analysis of placebo-controlled trials? Lancet 1997;350:834.
Linde K, Melchart D. Randomized controlled trials of individualized homeopathy: a state-of-the-art review. J Altern Complement Med 1998;4(4):371.
Linde K, Ramirez G, Mulrow CD, et al. St. John's wort for depression: an overview and meta-analysis of randomized clinical trials. Br Med J 1996;313:238.
Linde K, Streng A, Jurgens S, et al. Acupuncture for patients with migraine. JAMA 2005;293:2118.
Losier A, Taylor B, Fernandez CV. Use of alternative therapies by patients presenting to a pediatric emergency department. J Emerg Med 2005;28(3):267.
Lyon MR, Cline JC, Totosy de Zepetnek J, et al. Effect of the herbal extract combination Panax quinquefolium and Ginkgo biloba on attention-deficit hyperactivity disorder: a pilot study. J Psychiatry Neurosci 2001;26(3):221.
Martinet A, Hostettmann, Schutz Y. Thermogenic effects of commercially available plant preparations aimed at treating human obesity. Phytomedicine 2000;6(4):231.
Matthews MK. Association of Ginkgo biloba with intracerebral hemorrhage. Neurology 1998;50:1933.
Miller FG, Emanuel EJ, Rosenstein DL, et al. Ethical issues concerning research in complementary and alternative medicine. JAMA 2004;291:599.
Morris CA, Avorn J. Internet marketing of herbal products. JAMA 2003;290:1505.
Mostefa-Kara N, Pauwela A, Pines E, et al. Fatal hepatitis after herbal tea. Lancet 1992;340:674.
Newall C, Anderson L, Phillipson J. Herbal medicines: a guide for healthcare professionals. London: Pharmaceutical Press, 1996.
NIH Consensus Conference. Acupuncture. JAMA. 1998;280:1518.
O'Hara M, Kiefer D, Farrell K, et al. A review of 12 commonly used medicinal herbs. Arch Fam Med 1998;7:523.
Ohye H, Fukata S, Kanoh M, et al. Thyrotoxicosis caused by weight-reducing herbal medicines. Arch Intern Med 2005;165:831.
Ondrizck RR. An alternative medicine study of herbal effects on the penetration of zona-free hamster oocytes and the integrity of sperm deoxyribonucleic acid. Fertil Steril1999;71(3):517.
Palmer BV, Montgomery ACV, Monteriro JCMP. Ginseng and mastalgia. Br Med J 1996;313:253.
Pepper K, Trautwein W. The effect of aconitine on the membrane current in cardiac muscle. Pfluggers Arch 1967;296:328.
Pillans PI. Toxicity of herbal products. NZ MedJ 1995;108:469.
Piscitelli SC, Burstein AH, Chai HD, et al. Indinavir concentrations and St. John's wort. Lancet 2000;355:134.
Rose KD, Croissant PD, Parliament CF, et al. Spontaneous spinal epidural hematoma with associated platelet dysfunction from excessive garlic ingestion: a case report.Neurosurgery 1990;26:880.
Rotblatt M, Ziment I. Evidence based herbal medicine. Philadelphia: Hanley & Belfus, 2002.
Roulet M, Laurini R, Rivier L, et al. Hepatic veno-occlusive disease in a newborn infant of a women drinking herbal tea. J Pediatr 1988;112:433.
Rusy LM, Weisman SJ. Complementary therapies for acute pediatric pain management. Pediatr Clin North Am 2000;47(3):589.
Saper RB, Kales SN, Paquin J, et al. Heavy metal content of ayruvedic medicine products. JAMA 2004;292:2868.
Sawni-Sikand A, Schubiner H, Thomas RL. Use of complementary/alternative therapies among children in primary care pediatrics. Ambul Pediatr 2002;2(2):99.
Schoneberger D. Influence of the immunostimulating effects of the pressed juice of Echinaceae purpurae on the duration and intensity of the common cold: results of a double-blind clinical trial. Forum Immunol 1992;2:18.
Schulz V, Hansel R, Tyler VE. Rational phytotherapy: a physicians' guide to herbal medicine. Berlin: Springer-Verlag, 2004.
Shekelle PG, Hardy ML, Morton SC, et al. Efficacy and safety of ephedra and ephedrine for weight loss and athletic performance: a meta-analysis. JAMA 2003;289:1537.
Shelton RC, Keller MB, Gekenberg A, et al. Effectiveness of St. John's wort in major depression, a randomized control trial. JAMA 2001;285:1807.
Shang A, Huwiler-Muntener KH, Juni P, et al. Are the clinical effects of homeopathy placebo effects? Comparative study of placebo controlled trials of homeopathy and allopathy.Lancet 2005;366:726.
Sorrentino M. Garlic: is the “stinking rose” good for the cholesterol count? Altern Med Alert 1998;1(9):97.
Spigelblatt L, Laine-Ammara G, Pless IB, et al. The use of alternative medicine by children. Pediatrics 1994;94:811.
Stewart JH. Hypnosis in contemporary medicine. Mayo Clin Proc 2005;80:511.
Sticher O. Quality of ginkgo preparations. Planta Med 1993;59.
Stux G, Pomeranz B. Basics of Acupuncture. Germany: Springer-Verlag, 1998.
Tai Y, But P, Young K, et al. Cardiotoxicity after accidental herb-induced aconite poisoning. Lancet 1992;340:1254.
Taylor JA, Weber W, Standish L, et al. Efficacy and safety of Echinacea in treating upper respiratory tract infections in children: a randomized controlled trial. JAMA2003;290(21):2824.
Telles S, Joshi M, Dash M, et al. An evaluation of the ability to voluntarily reduce the heart rate after a month of yoga practice. Integr Physiol Behav Sci 2004;39(2):119.
Trigazis L, Tennankore D, Vohra S, et al. The use of herbal remedies by adolescents with eating disorders. Int J Eat Disord 2004;35(2):223.
Turner RB, Bauer R, Woelkart K, et al. An evaluation of Echinacea angustifolia in experimental rhinovirus infections. N Engl J Med 2005;353(4):337.
Udani JK, Ofman JJ. Echinacea for the common cold. Altern Med Alert 1998;1(2):16.
Wilson K, Klein J. Adolescents' use of complementary and alternative medicine. Ambul Pediatr 2002;2:99.
Wong AHC, Smith M, Boon HS. Herbal remedies in psychiatric practice. Arch Gen Psychiatry 1998;55:1033.
Woolf GM, Petrovic LM, Rojter SE, et al. Acute hepatitis associated with the Chinese herbal product Jin Bu Huan. Ann Intern Med 1994;121:729.
Yussman S, Auginger P, Weitzman M, et al. Complementary and alternative medicine use in children and adolescents. J Adolesc Health 2002;30:105.
Yussman S, Wilson K, Graff C, et al. Herbal products and their association with substance abuse in adolescents. J Adolesc Health 2002;30:122.