Use of complementary and alternative medicines in children Too important to ignore

Alissa Lim, Trainee Research Fellow Annette Webb, Paediatric Registrar Gill Kainey, RN, Clinical Support Services Kaye Hynes, Senior Pharmacist Noel Cranswick, Clinical Pharmacology Angela Mackenzie, Paediatrician Elizabeth Kennedy, Lawyer Liza Newby, Health Policy Consultant Mike South, Paediatrician

Natural Holistic Integrative Complementary Healing Alternative Unproven Whacky Dangerous Fraudulent

I thought I should mention doctor, that we have been giving him a Chinese herbal tonic to build up his strength for the operation next month.

That’s OK isn’t it?

The herbalist said we must keep giving it to him while he is in hospital for the operation. Can we do that?

I won’t be able to stay in overnight with him because I will need to be home for the other kids. Would it be OK for the nurses to give him the tonic when I’m not there?

Aims

• Present our own research • Present a new RCH policy and associated guidelines regarding CAM usage for RCH inpatients

Complementary and alternative medicine (CAM)

Complementary or Alternative Medicine (CAM) is a broad domain of healing resources that encompasses all health systems, modalities and practices and their accompanying theories and beliefs, other than those intrinsic to the politically dominant health system of a particular society.

Cochrane Collaboration

Examples

Medicines Herbal therapies Homeopathy Megavitamins Naturopathy Traditional Chinese Medicine Other therapies Acupuncture Chiropractic Ayurveda Aromatherapy Hypnotherapy Reiki Kinesiology Moxibustion Reflexology

Complementary and alternative medicine (CAM)

Diverse opinion amongst orthodox health professionals regarding role of CAM in health care. (Mirrored in our group)

Complementary and alternative medicine (CAM)

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It is likely that some forms of CAM are good therapies with important potential roles in health care.

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Some will be ineffective but harmless.

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Others will be dangerous.

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Every CAM has its own combination of risk & benefit.

(Just like orthodox therapies)

Alternative therapist faces questions after boy dies The Royal Children's Hospital has asked the Justice Department to investigate an alternative health practitioner who it believes advised the family of a teenage boy with curable cancer to stop chemotherapy.

The Age 21/09/2002

Special issues regarding CAM use in children

• Child not competent to make own decisions • Consequences of parental choice • ?Balance of parental autonomy and child’s wellbeing • Our responsibilities as health professionals

Non-medicine CAMs Consider individually

RCH CAM Research

Alissa Lim, Trainee Research Fellow Noel Cranswick, Clinical Pharmacologist Sue Skull, Clinical Epidemiologist Mike South, Paediatrician

CAM use in the Community

• Cross-sectional survey – Self-administered questionnaires – Random sample of 30 primary schools – Medication use in preceding two weeks – 1534 questionnaires

CAM use in the Community

Types of CAM

20% 15% 10% 5% 0% ns /M in er al s Tota l C A M V itami H er bal Ec hi nac ea H ome op ath ic

CAM use in the Community

50%

Reasons for Use

40% 30% 20% 10% 0% URTI General Health Skin Behaviour

CAM use in the Community

60% 50% 40% 30% 20% 10% 0%

Source of CAM

Self Initiated Naturopath Pharmacy /Shop Other CAM practitioners Doctor

RCH survey of CAM use

• A cross-sectional survey of inpatient and outpatients groups – Questionnaire by face-to-face interview – CAM use in the preceding 12 months – 503 patients surveyed • 101 inpatients and 402 outpatients (general paediatric, gastroenterology, thoracic, diabetes)

RCH survey of CAM use

60% 50% 40% 30% 20% 10% 0%

CAM Use

Total CAM Medicinal CAM Medicinal CAM (exclude vitamins only) Non-medicinal CAM

RCH survey of CAM use

20%

Types of Medicinal CAM

15% 10% 5% 0% Multi vitamins Vitamin C Echinacea Other Herbal Homeopathic

RCH survey of CAM use

35% 30% 25% 20% 15% 10% 5% 0%

Reasons for CAM Use

General Health URTI Dietary Supplement Skin GIT

RCH survey of CAM use

Had not told doctor

RCH survey of CAM use

• Inpatient group: – 22% had used medicinal CAM in last month – 2 patients (9%) documented – partial documentation only

CAM Adverse Events

• Surveillance Study via Australian Paediatric Surveillance Unit (APSU) • 29 reports over 20 months (January 2001 to September 2002) • Severity : mild to severe 2 fatality

CAM Adverse Events

Report Types: A.

Adverse events associated with the use of medicinal CAM B.

Adverse events associated with failure to use conventional therapy

CAM Valerian

CAM Adverse Events

ADVERSE EVENT Constipation

Colloidal silver Ginkgo and Ginseng *Crushed Pearl *“Infacalm” drops overdose Daily IM vitamin injections Homeopathic treatment and diet restriction * Mechanism unknown

Argyria Prolonged bleeding time Acidosis Hypoglycaemia, drowsiness, tachycardia Left sciatic neuropraxia and ongoing leg pain Malnutrition and sepsis

RCH CAM Research

• Common in the community • Very common in patients attending RCH ½ in last 12 months, ¼ in last month • Evidence of potential adverse effects or interactions.

• Families often don’t “tell”

RCH CAM Group DUC Subcommittee

• Policy • Guidelines • Resource documents • Drug Information Resources

Issues

• Acknowledge CAM is used for children and get it “out in the open” • Safety • Parental choice • Legal • Ethical • Documentation • Practical issues • Ward safety

RCH CAM Policy

RCH CAM Guidelines

General guideline for RCH Inpatients Ask all patients about current use of CAM Consider implications of CAM use (effects, interactions etc) for patient's condition Ring Drug Info - 9345 5208 Does parent wish to use CAM while child in hospital?

Yes Provide parent version of CAM policy No Discuss use of CAM outside hospital No Is the medicine eligible for approval It must have an AustL or AustR number No Ring Drug Info - 9345 5208 Yes Do parents insist on CAM usage in hospital?

Does the responsible consultant approve use of CAM for this patient?

Yes No Yes Record details in Medical Record Parents to sign the With Medical Approval section of Usage Statement (file in record) Record details in Medical Record Parents to sign the Against Medical Advice section of Usage Statement (file in record) Parent to supply CAM CAM record chart initiated CAM to be stored in ward drug cupboard Parents to administer and record on CAM record chart

? Child at risk

Use of CAM in exceptional circumstances where it is inappropriate/impossible for parents to administer it themselves. Examples Patient in ICU Parents unavailable to adminsister CAM themselves and wish hospital staff to do so in their absence Is the medicine eligible for approval It must have an AustL or AustR number Ring Drug Info - 9345 5208 Yes Does the responsible consultant approve use of CAM for this patient?

Yes No No Medicine NOT to be administered by hospital staff Is the patients consultant prepared to take full responsibility for the prescription of the medicine?

Yes No Are the nursing staff prepared to administer the medicine?

Yes No Medicine to be prescribed on usual prescribed drug section of medication chart.

Nurses to administer and record doses as for any other prescribed medication Record details in Medical Record Parents to sign Usage Statement Under no circumstances may hospital staff administer CAM to a patient outside this guideline even if an Use Against Medical Advice Statement has been signed

Working with families around CAM

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Whatever your views on CAM - it cannot be ignored, and it will not go away.

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If the parents of children you care for don’t tell about CAM use - there is the potential for an adverse outcome.

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Presenting an antagonistic attitude is unlikely to be helpful.

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Presenting an open-minded, non-judgmental attitude is likely to improve trust and understanding.

Resources www.rch.org.au/genmed/camguidelines.htm

The Drug Information Service – ext 5208.