Clinical Pediatrics

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Views of Pediatric Health Care Providers on the Use of Herbs and Dietary Supplements in Children Alan D. Woolf, Paula Gardiner, Julia Whelan, Hillel R. Alpert and Lana Dvorkin CLIN PEDIATR 2005 44: 579 DOI: 10.1177/000992280504400705 The online version of this article can be found at: http://cpj.sagepub.com/content/44/7/579

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Views of Pediatric Health Care Providers on the Use of Herbs and Dietary Supplements in Children Alan D. Woolf, MD, MPH1 Paula Gardiner, MD2 Julia Whelan, MS3 Hillel R. Alpert, ScM4 Lana Dvorkin, PharmD5

Summary: Herbs and dietary supplements (HDS) are widely used by adults for treating illnesses and/or preserving good health, and many parents use HDS for their children as well. Previous reports suggest parents will not divulge HDS use to health care providers for fear of their skepticism or disapproval. Yet the views of pediatric health care providers on HDS use in children are not well known. This study investigated the attitudes and practices of pediatric nurses and physicians regarding HDS use in children, in order to identify those characteristics associated with a high degree of confidence in initiating a dialogue on the topic of HDS with families in their practice. A written survey on attitudes and practices toward HDS was developed, piloted, revised, and then administered to a convenience sample of practitioners attending a regional postgraduate course in general pediatrics. Only 42% of 204 pediatric health care providers sampled felt confident in initiating discussions about the therapeutic use of herbs and dietary supplements with families in their practice. Confidence in discussing HDS with families correlated with both personal use of an HDS (OR 3.22; p=0.033) and length of time in practice less than 10 years (OR 8.26; p=0.007). Less than 18% felt that HDS were safe for children under 6 months of age; and only 35% felt they were safe for use in children < 24 months old. Only 7% felt that parents should be allowed to 1Division of General Pediatrics, Children’s Hospital, Boston, and Department of Pediatrics, give their hospitalized child an Harvard Medical School; 2Division of Community Practice, New England Medical Center and Department of Medicine, Tufts University School of Medicine; 3Treadwell Library, Massachusetts herb or dietary supplement General Hospital; 4Vital Sciences & Health, Newton, Massachusetts; 5Massachusetts College of they had brought with them Pharmacy and Allied Health Sciences, Boston, MA. from home, although this This study was supported in part by a grant (#AT005380-04) from the National Institutes of increased to 35% if the herb or Health (NIH), National Center for Complementary and Alternative Medicine (NCCAM), Bethesda, Maryland. The views in this paper are solely those of the authors and do not necessarily reflect dietary supplement had been the views of NCCAM. prescribed by a physician. This research was presented, in part, at the Pediatric Academic Societies Annual Meeting, San Ninety-two percent of Francisco, California, May 1, 2004. practitioners thought that Reprint requests and correspondence to: Alan Woolf, MD, MPH, Children’s Hospital, General Pediatrics, 1295 Boylston Street Suite 100, Boston, MA 02115. HDS should be more closely regulated by the FDA. Only a © 2005 Westminster Publications, Inc., 708 Glen Cove Avenue, Glen Head, NY 11545, U.S.A.

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Wo o l f e t a l . minority of pediatric community practitioners felt confident in discussing HDS with families of children in their practice. Those who had been in practice for a shorter time and who had used HDS themselves were more likely to report confidence in initiating such discussions. The provision of more postgraduate educational opportunities to learn about herbs and dietary supplements may alleviate some practitioners’ concerns about their own competency in discussing HDS with families in their practice. Clin Pediatr. 2005;44:579-587

Introduction

A

mericans spend more than $4.2 billion annually on herbs and dietary supplements to treat specific diseases or medical conditions and to safeguard and improve health.1 A dietary supplement is defined by the National Center of Complementary & Alternative Medicine as “a vitamin, a mineral, an herb or other botanical, an amino acid or dietary substance for use by man to supplement the diet.”2 Previous studies have shown that more than 50% of all young children and more than 30% of all adolescents in the United States have used a dietary supplement.3-8 A survey of 348 parents in primary care practices in Washington DC found that 21% had treated their child with complementary and alternative medicine (CAM) over the previous year; of those, 50% reported specific vitamin supplementation, 40% used herbal therapies, and 25% used other nutritional supplements or elimination diets.7 In another survey of 142 families in an emergency department, 45% of caregivers reported giving their child an herbal product.8 Children with chronic or recurrent conditions such as attention deficit hyperactivity disorder,9 asthma,7,10 atopic dermatitis,11 allergic rhinitis,12 cancer,13 inflammatory bowel disease,14 and rheumatoid arthritis15 all report high usage rates of herbs and dietary supplements (HDS).

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Despite the documentation of widespread interest in the therapeutic uses of HDS for children and adolescents, there are not much data on the views and practices of pediatricians and pediatric nurses concerning such uses. In one recent survey of 348 parents, 53% expressed the desire to discuss CAM with their pediatrician, increasing to 75% of those who used CAM themselves and 81% among those who used CAM for their children.16 Yet when taking a patient history or prescribing medication, nearly all pediatricians ask patients about their prescription and over-the-counter-medications but only about 1 in 5 pediatricians ask about HDS as well as special diets.17 Many patients do not divulge herb or dietary supplement use to practitioners for fear of their skepticism or disapproval. In one survey of 348 Michigan pediatricians, 30% thought that while herbs may be efficacious, they may also be harmful; less than 10% recommended dietary supplements in their practice and only 4% referred children for herbal medicine consultations.18 The purposes of the current study were threefold: to investigate the attitudes and practices of pediatric practitioners regarding HDS, to examine what differences may exist between nurses and physicians, and to distinguish associated factors found among those who professed confidence in discussing such therapies with families.

Design and Methods This investigation was a crosssectional study of health care professionals. A written survey on attitudes and practices related to HDS was developed, using some questions previously validated for an electronic educational program described elsewhere.19 Five domains of interest included: (1) personal use of herbs and dietary supplements, (2) confidence in discussing herbs and dietary supplements, (3) practice attitudes toward the use of herbs and dietar y supplements in children, (4) safety issues in the use of herbs and dietary supplements, and (5) resources used to acquire information on herbs and dietary supplements. The questions were piloted on a group of 10 health professionals in practice, and then revised. A convenience sample of pediatric health care providers was surveyed in April 2003 at a general pediatrics postgraduate course targeted at practitioners from the New England region. Cronbach’s alpha coefficients were calculated for the survey domains of interest. Scale interitem reliability coefficients varied by domain: personal use (21 items): 0.75; use of HDS in practice (5 items): 0.52; confidence in discussing HDS (2 items): 0.82; safety of HDS (7 items): 0.67; resources used to find information on HDS (17 items): 0.62 (see appendix 1).

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Practitioners’ Views on Herbs and Dietar y Supplements

APPENDIX 1: HERBS AND DIETARY SUPPLEMENTS (HDS) SURVEY 1. You are a (Check one): ■ Physician ■ Nurse Practitioner ■ Pharmacist ■ Nurse

■ Trainee ■ Social Worker ■ Other (explain): ______________________________________________

2. ■ Male

Years in Practice: _______

■ Female

3. How many patients do you see in an average WEEK? ■ 10–39 ■ 40–79

■ 0–9

Age: __________

■ 80 or more

4. Which HDS have you EVER used to treat yourself, even once (check as many as apply)? ■ Zinc ■ Multivitamins ■ Gingko ■ Ginseng ■ Echinacea ■ Chromium picolinate ■ Calcium ■ Vitamin E ■ Vitamin C ■ Sawgrass Palmetto ■ Other ■ None 5. Which HDS do you use to treat yourself ON A REGULAR BASIS (once monthly or more often)? ■ Zinc ■ Multivitamins ■ Gingko ■ Ginseng ■ Echinacea ■ Chromium picolinate ■ Calcium ■ Vitamin E ■ Vitamin C ■ Sawgrass Palmetto ■ Other ■ None 6. Have you ever recommended any HDS to children and families in your practice to treat medical conditions or to enhance their health? ■ YES ■ NO If so, which ones? ______________________________________________________________________________________ Strongly Agree

Agree

Neutral

Disagree

Strongly Disagree





















9. I feel confident about initiating discussions with my PATIENTS about HDS.











10. I feel confident about initiating discussions with my COLLEAGUES about HDS.





















12. Chinese patent medicines are generally safe because they have been used for thousands of years.











13. Families in my practice often ask me about HDS for use in treating their children.





















7. It is important to talk with PATIENTS about HDS as a therapeutic option, at least for some conditions. 8. It is important to talk with COLLEAGUES about HDS, at least for some patients with certain conditions.

11. The FDA should play a greater role in regulating HDS.

14. Some HDS are safe for use in treating infants < 6 months old

(continued)

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Wo o l f e t a l . Strongly Agree

Agree

Neutral

Disagree

Strongly Disagree

15. Some HDS are safe for use in treating infants 6–24 months old











16. Some HDS are safe for use in treating children 2–12 yrs old











17. Some HDS are safe for use in treating adolescents 13–19 yrs old











18. Some HDS are safe for use by pregnant women.











19. Some HDS are safe for use by lactating women.





















20. Children ADMITTED to the hospital should be allowed to take any HDS that parents bring with them from home.

21. What resources would you personally use to learn more about herbs and dietary supplements? (Choose as many as you like) ■ AAP publications ■ PDR reference ■ CME courses ■ Grand Rounds ■ Discussion with colleagues ■ Pediatrics textbooks ■ WebMD ■ Television features ■ Journal reviews & articles ■ Holistickids.com ■ Books on Herbs ■ Popular magazines ■ Internet Search Engine (e.g., Google) ■ Medline ■ Longwood Herbal Task Force ■ German E Monographs ■ Other Resources: __________________________

Confidence in discussing HDS with families was assessed by positive responses to questions regarding experience in prescribing HDS for patients or self-reported assessment of confidence in discussing HDS. Associations between diverse variables were tested—confidence and professional status (physician versus nurse), personal HDS use, age, gender, years in practice, and weekly case volume. Kruskal-Wallis contingency tables and Fishers’ Exact test were used for bivariate analyses. The Wilcoxon Rank Sum Test (MannWhitney U) was used for nonnormally distributed variables. A logit regression model was built to assess predictors of confidence in discussing HDS with families.

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Two-tailed alpha was set at 0.05 to determine statistical significance, and 95% confidence inter vals (CI) were calculated. This study was approved by the investigational review boards of the Children’s Hospital and the Massachusetts General Hospital, both in Boston.

Results Sample Of 234 course attendees, 204 (87%) completed usable questionnaires. Table 1 presents a profile of the sample, which included 85 physicians and 112 nurses (nurses and nurse practitioners were combined for comparative analyses); almost 86% of the sam-

ple were women. Respondents’ median time in practice was 26 years; their median age was 54 years. Fifty-nine percent had practice volumes > 40 patients/week. Tables 1 and 2 present practitioners’ views on their personal use of HDS, their professional practices, the safety of HDS, their confidence in discussing HDS, and resources used to find out more about HDS.

Personal Use of Herbs and Dietary Supplements Many pediatric health care providers (95%) in this sample indicated that they had used herbs and dietary supplements themselves in the past for their own health, but only 83% acknowledged regularly taking any HDS.

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Practitioners’ Views on Herbs and Dietar y Supplements

Table 1

PEDIATRIC HEALTH CARE PROVIDERS: SAMPLE CHARACTERISTICS AND ATTITUDES TOWARD THE USE OF HERBS AND DIETARY SUPPLEMENTS FOR CHILDREN Profession

Total

Percentage*

204

100%

Physician

85

41.7

Nurse

74

36.3

Nurse Practitioner

38

18.6

Other

7

03.4

175

85.8

Female Age (median)

54 years old

Patients per week (median)

40–79

Years in practice (median)

26 years

Personal use HDS (ever)

193

94.6

Personal use HDS(regular)

169

82.8

Recommend HDS to patients

143

70.1

Important to talk to families about HDS (n=200)

136

68.0

Important to talk to colleagues about HDS (n=199)

143

71.9

Confidence: talk to families about HDS (n=195)

82

42.1

Confidence: talk to colleagues about HDS (n=197)

100

50.8

FDA should play greater role in HDS (n=195)

180

92.3

Chinese patent medicines are safe (n=190)

15

7.9

HDS safe in infants < 6 months old (n=188)

33

17.6

HDS safe in infants