Herbal Remedies Used by Adolescents

Educational Objectives

The goals of this program are to improve the ability to counsel children and families of the use of herbs and supplements. After hearing and assimilating this program, the clinician will be better able to:

1. Describe the adverse effects of commonly used herbs and supplements.

2. Perform evidence-based assessments of the efficacy of many herbs and supplements.

3. List the nutritional supplements most commonly used by young athletes to improve performance.

Summary

Complementary and alternative medicine (CAM): estimated that 11% to 15% of well patients in general pediatric practice use herbs or supplements; in patients with chronic illness, rate of use ≈80%; 2012 National Health Interview Survey found 11.6% of healthy patients given CAM by parent; another study found individuals using CAM more likely to have anxiety, stress, or dermatologic conditions, and use strongly associated with use by parent; users more likely to live in West, Northeast, or Midwest, to have parent with college education, and to be taking prescription medication; conditions — survey from National Institutes of Health found 8.9% of patients use CAM (especially herbs) for back or neck pain; also used for, eg, colds, anxiety, and stress; other alternative interventions include chiropractic or osteopathic manipulation, deep breathing, homeopathy, meditation, and biofeedback

Dietary Supplement Health and Education Act of 1994 (DSHEA): for all supplements considered food (vitamins, minerals, herbs), testing for safety, efficacy, or contamination not required; products not subject to manufacturing standards (unless self-regulated); supplements may not claim curative properties (instead, products claim, eg, “supports immune system,” “enhances vitality”); Food and Drug Administration (FDA) approval not required; key safety messages not provided for herbs and supplements (including prescription interactions)

Herb-drug interactions: ask patients about supplements and herbs when discussing medication; patients assume products acceptable if not discussed; many herbs interfere with platelets or coagulation pathway (ask about use in patients who present, eg, after motor vehicle accident); most reputable supplement companies comply with Current Good Manufacturing Practices; check label for manufacturing standards (differs from FDA stamp); United States Pharmacopeia (USP) verification program also used; companies may pay ConsumerLab.com to test for contamination and consistency of dose between bottles (not for efficacy)

Supplements that affect coagulation pathway: echinacea; garlic; gingko biloba; may interfere with postoperative recovery time (coagulation or sedation); 26% of adults scheduled for surgery taking herb or supplement that requires discontinuation because of risk of bleeding or immunosuppression

Databases: International Bibliographic Information on Dietary Supplements focuses on efficacy rather than safety; Natural Medicines Comprehensive Database reviewed by pharmacists; lists mechanisms of action and efficacy

Caffeine: consumed as coffee, coffee drinks, energy drinks (eg, Red Bull, Monster), and oral supplement; reduces drowsiness, promotes alertness, and improves safety at work; improves high-intensity exercise performance; use illegal for athletes on scholarships; many adverse effects include anxiety, nervousness, peptic ulcer, and tremor

Echinacea: studies in rodents show stimulation of alternative complement pathway and activation of T-cells; immune modulating effects not demonstrated in humans; studies of use in children found no significant effect on recurrence of infection or severity of disease; Cochrane review (2014) found no benefit for treating common cold (possible weak benefit from some products; more study needed); placebo effect useful, but product not without risk; not recommended for patients undergoing chemotherapy or for those with arthritis or autoimmune illness; taken either as leaf (juice three times daily) or root (drops)

Zinc: Cochrane review (2013) found use of zinc for 5 consecutive days reduced duration of symptoms of common cold in adults (results mixed); excessive use causes temporary anosmia; may cause nausea or bad taste in mouth; speaker advises patients to begin ≤24 hr of symptom onset and use ≤5 days

Valerian: used as sleep aid; binds to γ-aminobutyric acid (GABA) receptors; study in adults found that 300 mg or 600 mg had no significant effect in sleep laboratory; combined with lemon balm, improves hyperactivity over 6 to 7 wk; may cause paradoxical anxiety or potentiate effect of barbiturates

St. John’s wort: used for depression; works as selective serotonin reuptake inhibitor (SSRI), by monoamine oxidase pathway, and by GABA pathway; Cochrane review (2005) found it more effective than placebo and about as effective as standard antidepressant for mild to moderate depression; studies evaluated use of herb (not extended-release formula) 3 times daily (0.3% hypericin); ensure use of USP labeling, expiration date, and childproof cap; concerns — induces cytochrome P450, increasing metabolism of oral contraceptive pills and making them less effective; can cause serotonin syndrome and photosensitivity; may interfere with metabolism of cyclosporine and other transplant medications (potential for rejection)

Butterbur: some neurologists recommend it to patients; open study found improvement in migraines; study found butterbur plus music therapy helps prevent migraine in children; 50 mg to 75 mg taken daily in 2 to 3 doses; adverse effects rare

Magnesium: effective for chronic migraines; cofactor in >300 enzyme systems; effective alone or combined with nonsteroidal anti-inflammatory drugs (NSAIDs); 300 mg to 500 mg taken daily; may cause diarrhea (start at low dose and increase slowly); proton pump inhibitors may reduce level; many neurologists recommend combination of magnesium, riboflavin, and feverfew (MigreLief) for migraine

Melatonin: used for jet lag and insomnia; works through GABA pathway; effective in children with chronic sleep-onset insomnia; meta-analysis (2013) found effective for primary sleep disorders; studies in children on autism spectrum show efficacy for sleep difficulties; caveats — hormone (not herb) made from ground bovine pineal gland; synthetic product also available; 0.5 mg to 5 mg studied; speaker does not recommend dose >3 mg; recommends use for 5 to 6 wk, then discontinuation for 2 to 3 wk; affects ovulation pathway and impairs glucose utilization (long-term use inadvisable in patients with diabetes)

Omega-3 fatty acids: used for, eg, attention-deficit/hyperactivity disorder, depression, and prevention of macular degeneration in adults; seems to reduce serum triglyceride levels; fish oil seemingly helpful for some psychiatric disorders; reduces requirement for increased dose of SSRI; decreases tics in patients with Tourette syndrome; 5 g taken daily; fishy taste and belching occur in ≈30% of those taking fish oil (recommend products with different source)

Peppermint: used for irritable bowel syndrome (IBS), colic, nausea, and congestion, for topical analgesia, and as calcium channel blocker (relaxes smooth muscle); excessive use can relax gastroesophageal sphincter and cause heartburn; topical use of oil for IBS (applied to abdomen) helpful in adults; Kline et al (2001) found use of oil in children decreased symptoms of IBS by 75% (1-2 enteric coated capsules); important to recommend enteric capsule, not tea, to avoid relaxing esophagus and stomach

Arnica: used topically for aches and sprains; study found decreased muscle pain with application over bruised or sore area; avoid use in open wound; also effective for pain caused by chemotherapy; not to be taken orally; avoid in patients with allergy to Compositae family

Chamomile: contains chamazulene, apigenin, and bisabolol; study showed improvement in colic symptoms in breastfed infants; another study found it effective at reducing symptoms in patients with generalized anxiety disorder; used as tea; small amounts used for infants (5-6 drops in breastmilk or formula); efficacy when used by breast-feeding mother unknown

Ginger: effective for nausea from pregnancy or chemotherapy; excessive use may cause heartburn; interferes with platelet aggregation (use caution in patient taking NSAID or aspirin)

Resources: American Academy of Pediatrics provides listserve and statement on efficacy and safety of integrative medicine

Questions and answers: essential oils — postoperative inhaled lavender decreases use of patient-controlled analgesia; topical lavender oil associated with prepubertal gynecomastia in boys; oils degrade if not kept in lightproof bottle; discard after 1 yr; fenugreek — effective for increasing production of breast milk (recommended for 2-3 days only); caffeine — can elevate blood pressure; MigreLief and butterbur — may use together; melatonin — not replacement for good sleep hygiene

Readings

Adkison JD et al: The effect of topical arnica on muscle pain. Ann Pharmacother 2010 Oct;44(10):1579-84; Ferracioli-Oda E et al: Meta-analysis: melatonin for the treatment of primary sleep disorders. PLoS One 2013 May 17;8(5):e63773. doi:10.1371/journal.pone.0063773; Gromball J et al: Hyperactivity, concentration difficulties and impulsiveness improve during seven weeks’ treatment with valerian root and lemon balm extracts in primary school children. Phytomedicine 2014 Jul-Aug;21(8-9):1098-103; Karsch-Völk M et al: Echinacea for preventing and treating the common cold. Cochrane Database Syst Rev 2014 Feb 20;(2):CD000530. doi:10.1002/14651858.CD000530.pub3; Kline RM et al: Enteric-coated pH-dependent peppermint oil capsules for the treatment of irritable bowel syndrome in children. J Pediatr 2001 Jan;138(1):125-8; Linde K et al: St John’s wort for depression. Cochrane Database Syst Rev 2005 Apr 18;(2):CD000448. doi:0.1002/14651858.CD000448.pub2; McClafferty H et al; Section on Integrative Medicine: Pediatric Integrative Medicine. Pediatrics 2017 Sep;140(3):pii:e20171961. doi:10.1542/peds.2017-1961; Singh M et al: Zinc for the common cold. Cochrane Database Syst Rev 2013 Jun 18;(6):CD001364. doi:10.1002/14651858.CD001364.pub4.

Disclosures

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning committee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest.

Acknowledgements

Dr. Breuner was recorded at Aloha Update: Pediatrics 2018, presented by the American Academy of Pediatrics, California District IX, Chapter 2, in association with Children’s Hospital Los Angeles Medical Group, and held October 20-26, 2018, on Kauai, HI. For information about upcoming CME conferences from the Children’s Hospital Los Angeles Medical Group, please visit www.chla.org/cme-conferences. The Audio Digest Foundation thanks Dr. Breuner, the American Academy of Pediatrics, California District IX, Chapter 2, and the Children’s Hospital Los Angeles Medical Group for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

PD651401

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.