CAM for KIDS: more good than harm?

Adults using unproven treatments is one thing; if kids do it because they are told to, that is quite another thing. Children are in many ways more vulnerable than grown-ups and they usually cannot give fully informed consent. It follows that the use of such treatments for kids can be a delicate and complex matter.

A recent systematic review was aimed at summarizes the international findings for prevalence and predictors of complementary and alternative medicine (CAM) use among children/adolescents. The authors systematically searched 4 electronic databases (PubMed, Embase, PsycINFO, AMED; last update in 07/2013) and reference lists of existing reviews and all included studies. Publications without language restriction reporting patterns of CAM utilization among children/adolescents without chronic conditions were selected for inclusion. The prevalence rates for overall CAM use, homeopathy, and herbal drug use were extracted with a focus on country and recall period (lifetime, 1 year, current use). As predictors, the authors extracted socioeconomic factors, child‘s age, and gender.

Fifty-eight studies from 19 countries could be included in the review. There were strong variations regarding study quality. Prevalence rates for overall CAM use ranged from 10.9 – 87.6 % for lifetime use, and from 8 – 48.5 % for current use. The respective percentages for homeopathy (highest in Germany, United Kingdom, and Canada) ranged from 0.8 – 39 % (lifetime) and from 1 – 14.3 % (current). Herbal drug use (highest in Germany, Turkey, and Brazil) was reported for 0.8 – 85.5 % (lifetime) and 2.2 – 8.9 % (current) of the children/adolescents. Studies provided a relatively uniform picture of the predictors of overall CAM use: higher parental income and education, older children. But only a few studies analyzed predictors for single CAM modalities.

The authors drew the following conclusion: CAM use is widespread among children/adolescents. Prevalence rates vary widely regarding CAM modality, country, and reported recall period.

In 1999, I published a very similar review; at the time, I found just 10 studies. Their results suggested that the prevalence of CAM use by kids was variable but generally high. CAM was often perceived as helpful. Insufficient data existed about safety and cost. Today, the body of surveys monitoring CAM use by children seems to have grown almost six-fold, and the conclusions are still more or less the same – but have we made progress in answering the most pressing questions? Do we know whether all these CAM treatments generate more good than harm for children?

Swiss authors recently published a review of Cochrane reviews which might help answering these important questions. They performed a synthesis of all Cochrane reviews published between 1995 and 2012 in paediatrics that assessed the efficacy, and clinical implications and limitations of CAM use in children. Main outcome variables were: percentage of reviews that concluded that a certain intervention provides a benefit, percentage of reviews that concluded that a certain intervention should not be performed, and percentage of studies that concluded that the current level of evidence is inconclusive.

A total of 135 reviews were included – most from the United Kingdom (29/135), Australia (24/135) and China (24/135). Only 5/135 (3.7%) reviews gave a recommendation in favour of a certain intervention; 26/135 (19.4%) issued a conditional positive recommendation, and 9/135 (6.6%) reviews concluded that certain interventions should not be performed. Ninety-five reviews (70.3%) were inconclusive. The proportion of inconclusive reviews increased during three, a priori-defined, time intervals (1995-2000: 15/27 [55.6%]; 2001-2006: 33/44 [75%]; and 2007-2012: 47/64 [73.4%]). The three most common criticisms of the quality of the studies included were: more research needed (82/135), low methodological quality (57/135) and small number of study participants (48/135).

The Swiss authors concluded that given the disproportionate number of inconclusive reviews, there is an ongoing need for high quality research to assess the potential role of CAM in children. Unless the study of CAM is performed to the same science-based standards as conventional therapies, CAM therapies risk being perpetually marginalised by mainstream medicine.

And what about the risks?

To determine the types of adverse events associated with the use of CAM that come to the attention of Australian paediatricians. Australian researchers conducted a monthly active surveillance study of CAM-associated adverse events as reported to the Australian Paediatric Surveillance Unit between January 2001 and December 2003. They found 39 reports of adverse events associated with CAM use, including four reported deaths. Reports highlighted several areas of concern, including the risks associated with failure to use conventional medicine, the risks related to medication changes made by CAM practitioners and the significant dangers of dietary restriction. The reported deaths were associated with a failure to use conventional medicine in favour of a CAM therapy.

These authors concluded that CAM use has the potential to cause significant morbidity and fatal adverse outcomes. The diversity of CAM therapies and their associated adverse events demonstrate the difficulty addressing this area and the importance of establishing mechanisms by which adverse effects may be reported or monitored.

So, we know that lots of children are using CAMs because their parents want them to. We also know that most of the CAMs used for childhood conditions are not based on sound evidence. The crucial question is: can we be sure that CAM for kids generates more good than harm? I fear the answer is a clear and worrying NO.