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

Use of complementary and Use of complementary and alternative medicines in children alternative medicines in children

Too important to ignoreToo important to ignoreAlissa 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

Complementary

Alternative

Natural

WhackyHolistic

Integrative

Unproven

Dangerous

FraudulentHealing

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?

AimsAims

• Present our own research

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

Complementary and Complementary and alternative medicine (CAM)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

ExamplesExamples

MedicinesHerbal therapies Naturopathy

Homeopathy Traditional Chinese Medicine

Megavitamins

Other therapiesAcupuncture Aromatherapy Kinesiology

Chiropractic Hypnotherapy Moxibustion

Ayurveda Reiki Reflexology


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


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

• Some will be ineffective but harmless. • Others will be dangerous. • 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 Special issues regarding CAM use in childrenCAM 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 CAMsNon-medicine CAMsConsider individuallyConsider individually

RCH CAM Research RCH CAM Research

Alissa Lim, Trainee Research Fellow

Noel Cranswick, Clinical Pharmacologist

Sue Skull, Clinical Epidemiologist

Mike South, Paediatrician

CAM use in the CAM use in the CommunityCommunity

• Cross-sectional survey

– Self-administered questionnaires

– Random sample of 30 primary schools

– Medication use in preceding two weeks

– 1534 questionnaires


0%

5%

10%

15%

20%

Types of CAM


0%

10%

20%

30%

40%

50%

URTI General

Health

Skin Behaviour

Reasons for Use

CAM use in the CAM use in the Community Community

0%

10%

20%

30%

40%

50%

60%

Self Initiated Naturopath Pharmacy/Shop

Other CAMpractitioners

Doctor

Source of CAM

RCH survey of CAM useRCH 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)


0%

10%

20%

30%

40%

50%

60%

Total CAM MedicinalCAM

MedicinalCAM (excludevitamins only)

Non-medicinalCAM

CAM Use

RCH survey of CAM useRCH survey of CAM useTypes of Medicinal CAM

0%

5%

10%

15%

20%

Multivitamins

Echinacea HomeopathicVitamin C Other Herbal


0%

5%

10%

15%

20%

25%

30%

35%

GeneralHealth

URTI DietarySupplement

Skin GIT

Reasons for CAM Use


Had not tolddoctor


• Inpatient group:

– 22% had used medicinal CAM in last month

– 2 patients (9%) documented

– partial documentation only

CAM Adverse EventsCAM 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 EventsCAM Adverse EventsReport Types:

A. Adverse events associated with the use of medicinal CAM

B. Adverse events associated with failure to use conventional therapy

CAM Adverse EventsCAM Adverse EventsCAM ADVERSE EVENT

Valerian Constipation

Colloidal silver Argyria

Ginkgo and Ginseng Prolonged bleeding time

*Crushed Pearl Acidosis

*“Infacalm” dropsoverdose

Hypoglycaemia,drowsiness, tachycardia

Daily IM vitamin injections Left sciatic neuropraxia andongoing leg pain

Homeopathic treatmentand diet restriction

Malnutrition and sepsis

* Mechanism unknown

RCH CAM ResearchRCH 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 GroupRCH CAM GroupDUC SubcommitteeDUC Subcommittee

• Policy

• Guidelines

• Resource documents

• Drug Information Resources

IssuesIssues• 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 PolicyRCH CAM Policy

RCH CAM GuidelinesRCH CAM Guidelines

? Child at risk

Ask all patients about current use of CAM

Discuss use of CAM outside hospital

Record details in Medical Record Parents to sign the With Medical

Approval section of Usage Statement (file in record)

Does the responsible consultant approve use of

CAM for this patient?

Provide parent version of CAM policy

Does parent wish to use CAM while child in

hospital?

Consider implications of CAM use (effects, interactions etc)

for patient's conditionRing Drug Info - 9345 5208

Record details in Medical Record Parents to sign the Against Medical Advice section of Usage Statement

(file in record)

Parent to supply CAMCAM record chart initiated

CAM to be stored in ward drug cupboard

Do parents insist on CAM usage in hospital?

No

No

No

Yes

Yes

Yes

General guideline for RCH Inpatients

Is the medicine eligible for approval It must have an AustL or AustR number

Ring Drug Info - 9345 5208

No

Yes

Parents to administer and record on CAM record chart

Use of CAM in exceptional circumstances where it is inappropriate/impossible for parents to administer it themselves.

Does the responsible consultant approve use of CAM for this

patient?

Medicine NOT to be administered

by hospital staff

No

Is the medicine eligible for approvalIt must have an AustL or AustR

number Ring Drug Info - 9345 5208

No

Yes

Is the patients consultant prepared to take full responsibility for the

prescription of the medicine?

Yes

No

Examples Patient in ICU Parents unavailable to adminsister CAM themselves and wish hospital staff to do so in their absence

Are the nursing staff prepared to administer the medicine?

No

Yes

Medicine to be prescribed on usual prescribed drug section of medication

chart.Nurses to administer and record doses as for any other prescribed medication

Yes

Record details in Medical RecordParents 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 Working with families around CAMaround CAM

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

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

• Presenting an antagonistic attitude is unlikely to be helpful.

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

ResourcesResources

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

The Drug Information Service – ext 5208.

Documents

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