Herbal Remedies and Children: Do They Work? Are They Harmful? Alan D. Woolf, MD, MPH ABSTRACT. More parents are considering the use of vitamins rose from $0.9 billion in 1990 to $3.3 billion herbal remedies to maintain their children’s good health in 1997. Americans spent more than $5.1 billion on and to treat their illnesses. They look to pediatricians and herbal products and $1.7 billion on dietary supple- other primary care clinicians for advice concerning the ments in 1997.3 Such products are now being mar- safety and efficacy of herbal products for children. This keted to parents for the treatment of their children. article reviews principles for the clinician to keep in In this review, only 1 modality within CAM—the mind while investigating the literature on herbal medi- cine and addressing the use of herbal medicines with use of herbal products to treat children’s health con- parents. Pediatrics 2003;112:240–246; herbs, dietary sup- ditions—is addressed. Herbal medicines are touted plements, herbal remedy, pediatric herbs, children’s herbs, to the public as less toxic and more effective than complementary and alternative medicine. conventional drugs for various ailments because they are “natural” and their efficacy is based on knowledge gained over thousands of years. Al- ABBREVIATIONS. CAM, complementary and alternative medi- cine; DSHEA, Dietary Supplement Health and Education Act; though one can dispute the theory, pediatricians and FDA, Food and Drug Administration. other primary care clinicians cannot afford to ignore the reality, which is that herbal medicines, having potential benefits and toxicities, are a newly emerg- omplementary and alternative medicine ing growth industry in the United States. In Europe, (CAM) refers to diagnostic and therapeutic Asia, and elsewhere, their use has long been more Csystems that are not encompassed within the accepted. practice of allopathic medicine. The National Center for Complementary and Alternative Medicine at the National Institutes of Health defines CAM as “a HERBAL DEFINITIONS broad domain of healing resources that encompasses Herbs that are used for medicinal purposes come all health systems, modalities, and practices and their in a variety of forms. Active parts of a plant may accompanying theories and beliefs, other than those include leaves, flowers, stems, roots, seeds, and ber- intrinsic to the politically dominant health system of ries. They may be taken internally as pills or pow- a particular society or culture in a given historical ders, dissolved into tinctures or syrups, or brewed in period.”1 CAM is widely practiced in the United teas and decoctions. Salves, ointments, shampoos, or States. In a 1990 telephone survey of 1539 US adults, poultices may be applied to the skin, scalp, or mu- 34% reported using at least 1 unconventional therapy cous membranes. within the previous year.2 Extrapolations of the data Many plants contain essential oils that are dis- suggested that Americans make 425 million visits tilled, packaged, and sold unregulated to the public annually to providers of unconventional therapies for medicinal purposes. Essential oils include any of (but only 388 million visits to primary care clini- a class of volatile oils composed of a mixture of cians), spending approximately $13.7 billion, of complex hydrocarbons (often terpenes, alkaloids, which $10.3 billion was out-of-pocket, on alternative and other large molecular weight compounds) ex- 4 remedies. By 1997, a comparable study found that tracted from a plant. Essential oils give the plant its 42% of Americans made Ͼ629 million visits to pro- characteristic aroma and will evaporate quickly from viders of unconventional therapy (as opposed to 387 the skin or another surface; they are so concentrated million visits to primary care clinicians) and spent that, if applied directly to the skin, they will often Ͼ$27 billion on CAM, much of it out-of-pocket.3 cause inflammation and dermatitis. Fixed oils are Among US adults in 1997 who reported the fre- nonvolatile oils made of long-chain fatty acids, such quent use of prescription medications, 1 in 5 concur- as mineral oil or safflower oil. These are often used as rently took herbal remedies or high-dose vitamins. carriers into which a few drops of the very concen- Estimated out-of-pocket expenditures for high-dose trated essential oil are diluted during their applica- tion. Resins are solid or semisolid organic substances found in plant secretions; they are usually applied From the Department of Pediatrics, Harvard Medical School; Program in Clinical Toxicology, Children’s Hospital; and Massachusetts/Rhode Island topically as creams or ointments. Poison Control Center, Boston, Massachusetts. There are several terms used in the context of Received for publication Jul 26, 2002; accepted Jan 17, 2003. herbal therapy that are useful to know. Aroma- Reprint requests to (A.D.W.) Program in Environmental Health, Children’s therapy involves the inhalation of volatile oils to Hospital, 1295 Boylston St, Ste 100, Boston, MA 02115. E-mail: [email protected] treat certain health problems. A carminative is an PEDIATRICS (ISSN 0031 4005). Copyright © 2003 by the American Acad- agent that aids in expelling gas from the gastrointes- emy of Pediatrics. tinal tract. A rubefacient reddens the skin via cuta- 240 PEDIATRICS Vol. 112Downloaded No. 1 July from 2003www.aappublications.org/news by guest on September 26, 2021 neous vasodilation. An emmenagogue influences from foxglove leaves) suggests that some herbs may menstruation; an abortifacient induces abortion. The prove to be effective remedies for treating medical “discipline of signatures” is a historical term suggest- diseases. Angell and Kassirer8 stated that there is no ing that the appearance of a plant or its extract gives such thing as an “alternative” medicine but only that a clue as to its medicinal value. For example, because for which effectiveness has been confirmed using the the extract in St John’s wort is red, this would imply scrutiny of evidence-based science. Thus, any claims that it is restorative for conditions involving the of health benefits from an herbal remedy should be blood. subjected to the scrutiny of evidence-based medicine. The scientific criteria for causal associations include CHARACTERISTICS OF PATIENTS USING HERBAL biological plausibility, consistency of research re- REMEDIES sults, dose-response effects, reproducibility of the The use of herbs has been popularized with satu- research in different contexts using different meth- ration marketing such that they are available in phar- odologies, the strength of the association, and a cor- macies, grocery stores, and other outlets. Families rect temporality between cause and effect. Using this with children who have chronic medical conditions, level of scientific precision, studies of some herbal such as autism, cystic fibrosis, rheumatoid arthritis, remedies have revealed promising results. For exam- or asthma, may be particularly likely to pursue ple, tea tree oil has been found to inhibit the growth herbal remedies as part of their treatment regimen. of certain dermatophytes and may be useful for fun- The American Academy of Pediatrics’ Committee on 9 Children with Disabilities recently issued guidelines gal skin conditions. In laboratory studies, some es- for discussing such issues with parents of children sential oils have been demonstrated to have antimi- 10,11 with chronic health problems, acknowledging the crobial actions. Artemisia species have compared frequency with which such families may seek alter- favorably with chloroquine in the treatment of some 12,13 native treatments.5 types of malaria. Astragalus membranaceus ex- In 1 survey, 11% (or 208 children) of families (n ϭ tracts enhanced the antibody response to a T cell– 1911) that used the outpatient clinics of the Univer- dependent antigen in immunosuppressed mice.14 In sity of Montreal for their children’s care sought CAM 1 study, herbal teas that contained chamomile for medical conditions.6 This is probably an under- seemed to have a favorable effect on infantile colic.15 estimate, because the study was conducted years ago St John’s wort (Hypericum perforatum) may affect se- and surveyed a selected population. The families rotonin receptor expression in the brain; such actions indicated that they sought help from a variety of might underlie the efficacy of H perforatum extract in practice types, including chiropractic (36%), home- alleviating mild depression in adults.16 Whereas a opathy (25%), naturopathy (11.5%), acupuncture recent randomized, controlled trial showed no effect (11.5%), osteopathy (9%), oligotherapy (4%), and of St John’s wort on depression,17 such controlled other (3%). They used CAM for respiratory tract studies of the beneficial effects of St John’s wort in illnesses (37%); ear, nose, and throat conditions children with depression or other conditions are (24%); musculoskeletal conditions (15%); skin condi- lacking. Echinacea (Echinacea purpurea) has been tions (6%); gastrointestinal conditions (6%); allergies found to be a potent activator of the immune system. (6%); prevention (5%); and other conditions (11%). It increases the number and phagocytic performance A profile of adult CAM users found that they were of granulocytes,18 activates macrophages19 and T highly educated individuals of a high socioeconomic lymphocytes,20 causes elaboration of cytokines,21 status who often were treating their own chronic and has ill-defined antiviral properties.22 Such im- medical problems refractory to conventional medical 7 mune changes may explain why echinacea has been management. Many reasons were put forward as to advocated to shorten the course and severity of up- why these adults choose to seek CAM. They may per respiratory infections in adults; some controlled hold values systems that emphasize natural, holistic, studies are promising.23,24 The usefulness of echina- and organic products or may have had a transforma- cea for alleviating symptoms of respiratory infec- tional experience that changed the way they view the tions in children has yet to be demonstrated.