As more parents treat childhood ills with supplements and herbs, physicians are trying to set guidelines and clarify the products' risks and benefits.

By Hilary E. MacGregor, LA Times Staff Writer
April 3, 2006

GUMMY VITES. Strawberry Flavored Fish Oil. Super Kids Salve. Gum-omile Oil. Children's Echinacea. Herbs for Kids.

Squeezed onto the shelves of your local drugstore, near the baby aspirin and children's Robitussin, is a steadily growing crowd of colorful supplements and herbs specifically for children. To many parents, these products are a safe first-defense against the aches and pains of childhood, ones that can be tried before drugs with their sometimes risky side effects.

"I trust Western medicine," said Westside resident Lauren Sands, while shopping at the Santa Monica Homeopathic Pharmacy recently for her 5-month-old son. "I just want to know if there is something gentler for a little boy."

Other parents use the products as a tried-and-true, less-expensive alternative to medication. Many of these parents are uninsured, but not all.

"When I ask them about herbs and supplements, more and more of my patients are saying, 'Yes, I am using these products with my kids," said Dr. Paula Gardiner, a clinical research fellow at Harvard Medical School . "And looking at the data about pediatricians and kids, more and more doctors are getting asked questions about herbs and supplements."

But doctors and health experts are only just now beginning to fully understand how many parents are turning to such products. As they do so, they're scrambling to quantify the products' use, their risks and their benefits.

Gardiner, for example, who has done extensive research on alternative therapies, is doing her best to mine existing data. She is crunching numbers from the 1999-2002 National Health and Nutrition Examination Survey — which interviewed 11,000 people, including 5,000 kids — and trying to figure out which supplements kids are using.

Other doctors are trying to come up with guidelines to help pediatricians talk to parents about herb use.

"What we are saying is, 'Ask the question,' " said Dr. Sunita Vohra, who sits on a committee of the Provisional Section on Complementary, Holistic and Integrative Pediatrics for the American Academy of Pediatrics, which is developing a set of guidelines for herb use in children. "Talk openly. Be nonjudgmental and supportive [of parents]. Then, as the evidence accumulates, providers will be more comfortable making actual recommendations."

A few researchers, such as naturopathic doctor Wendy Weber of Bastyr University in Seattle , are conducting desperately needed clinical trials on kids and herbs. Weber has been studying the effectiveness of echinacea in treating colds in children, the possibility of using a certain herb to treat attention deficit hyperactivity disorder, and examining the potential of St. John's wort to treat depression in children. So far, she says, the results have been mixed.

The need for more information is crucial. Most doctors are not trained in herb use, researchers are still uncertain of how herbs interact with conventional drugs, and studies on herbal use in children are scant.

"All their organs are still developing," said Dr. Kathi Kemper, head of holistic and integrative medicine at Wake Forest University School of Medicine. "Their brains are still developing. They have higher metabolisms. Their hearts beat faster. The effect in the growing developing system of a child may be different than in a grown person."

Children are also more susceptible to toxic substances, such as lead, that can affect their nervous systems, said Kemper, author of "The Holistic Pediatrician." And there is a fair risk of contamination in herbal products, she said, because herbs, unlike conventional drugs, are not tested before they reach the market.

Despite the risks, she and a growing number of physicians say, parents who want to use a more natural remedy can safely do so — for some conditions. The key is to know the risks and the limitations of herbs, be on the alert for side effects, and let the child's doctor know of any supplements, because they might interact with medications.

Use may be widespread

Neither product manufacturers nor medical researchers have established the precise extent of complementary and alternative medicine use in children.

But companies such as Herb Pharm, which sells several herbal children's products, and Botanical Labs, which sells a line of 25 products for children, say they have seen steady growth over the past decade. And several recent studies suggest supplement use by children is indeed widespread — and underreported.

A survey of 2,600 low-income parents and caregivers published in the February issue of the Journal of the American Dietetic Assn. found that nearly half of Latino children and nearly one-third of non-Latino children had been given medicinal herbs. The botanical treatments were most often used for common ailments such as diaper rash, colic, teething symptoms, stomachaches, coughs and colds. The majority of the children were younger than 5.

Dr. Barbara Lohse, associate professor of nutritional sciences at Penn State , said she and her colleagues were "surprised" at the number of parents using herbs for their children.

"We worried that if we talked about herbs parents will go out and start using herbs like crazy," she said. "What this shows is that people are already using them. They are going to use herbs — at the same time they are coming to receive standard care."

Most caregivers were using herbs widely regarded as safe — ginger, garlic, peppermint, lavender, chamomile and cranberry. But, she said, some used the herbs incorrectly — administering them in the wrong doses or for the wrong ailment — or gave their children herbs widely viewed as dangerous, such as dong quai, which can increase sensitivity to sunlight and cause rashes.

A 2002 survey found that of 828 calls to the California Poison Control System, 134 were about adverse events involving children who had taken dietary supplements. The symptoms included agitation, vomiting, nausea and increased heart rate.

Because not all products create such symptoms, use of them can escape the notice of physicians and health-care workers — unless they ask.

A 1998 survey — of 348 patients in four Washington , D.C. , pediatric clinics — found that 20% of children had been treated with complementary or alternative therapies. Of those, 50% had been given vitamins, 25% had been given other nutritional supplements, and more than 40% had been treated with herbal products.

Only one-third had told their child's pediatrician about the products.

The risks of unsupervised supplement use increases when a child has a chronic illness or is about to undergo surgery. Because those children are most likely to be taking medication, the potential for a dangerous drug-herb interaction is great.

A University of Washington study published last year in the journal Paediatric Anaesthesia found that 3.5% of pediatric surgical patients were given herbs or homeopathic remedies during the two weeks before their operations.

A similar 2004 study, which appeared in the Journal of Clinical Anesthesia, found that 13% of children had used herbal remedies in the year before their operations.

Another study of more than 500 children with serious chronic conditions, such as cystic fibrosis, cancer, diabetes and neurobehavioral disorders, found that 62% of them used dietary supplements, and only one-third of those had talked to their doctor about it.

"Communication should be as complete as possible," Kemper said. "If the child's tummy ache improved with peppermint, it's better for the peppermint to get the credit than an unused prescription, and it helps the pediatrician know what's working and what's not. Also, it's important to know in case the child has an allergic reaction, and to check for potential interactions."

If, for example, a child with asthma is taking both the prescription drug prednisone and licorice recommended by a Chinese herbalist, the child's immune system can become dangerously suppressed, Gardiner said. "Remember, an herb is a drug," she said. "Just because it is natural doesn't mean it is safe."

But Millicent Frost, mother of a 17-month-old, said she would talk to her homeopathic doctor, not her pediatrician, about specific botanical remedies. She has food allergies and frequently uses supplements and other herbs to treat her symptoms. She often does her own research about which herbs and medicines to use for her son, but sometimes turns to someone she considers an expert. "I have a girlfriend with nine kids," she said. "I ask her."

Traditionally, that is how mothers treated sick children. They relied on parents and relatives with more experience to share their community's folk remedies.

Old remedies passed down

Indeed, many of the popular plant remedies people used on children two centuries ago were passed down from generation to generation until the advent of penicillin, says Michael McGuffin, president of the American Herbal Products Assn., an industry trade group. With the development of the antibiotic, parents began to turn to outside experts to treat even mild childhood diseases. By 1980, when the herbal product market began to take off, most of that traditional knowledge had been lost.

Today's commercially prepared potions, pills and salves, however, don't come with the collective folk wisdom garnered from years of use. These days, parents — or their kids — are largely on their own with the products. The dangers are often unexpected.

Ma huang, for example, was used to treat asthma and allergies in China for 5,000 years, but didn't become popular in the United States until the 1970s. Because it is a stimulant that can produce euphoria and increase sexual sensation, teens began using it in the 1980s as "herbal ecstasy." More than 30 died.

Further, because herbal remedies are not regulated like drugs, there's little guarantee that the product is accurately labeled and free of contamination.

Parents should especially avoid Chinese patent medicines (ready-made preparations from traditional Chinese herbalists) and Ayurvedic medicines made outside the United States , physicians and herb experts say. A small study last year found that 20% of 70 Ayurvedic herbal products sold in ethnic groceries in the greater Boston area contained enough lead, mercury and arsenic to be toxic if used as directed. Half of those dangerous products were specifically recommended for pediatric use.

Gardiner, the alternative medicine researcher, said she often encourages patients to use the herbs that are already in their kitchens. Ingredients such as oatmeal and chamomile are calming, and garlic and oregano can ease cold and flu symptoms, she said.

In the absence of clinical trials, parents should consider how herbs are used traditionally, she said.

"It's sort of back to the future," Kemper said. "Two hundred years ago we only used herbs and supplements, then along came prescription medications and we stopped using as many home remedies. And now that we are more aware that not all drugs are miracle drugs, and many drugs have side effects, we're back to using more home remedies. But doctors are slower to start using them again than parents are."

Vohra, director of the complementary and alternative research program at the Stollery Children's Hospital in Edmonton , Canada , sees herbs and supplements as pediatrics' newest sub-specialty.

"It is one thing to say please ask the question," she said. "But pediatricians don't necessarily have the expertise to know what to do with the answer."

Eventually, she says, pediatricians might be able to refer patients to a pediatric integrative medicine specialist. Until then, she says, a rudimentary knowledge of herb and supplement use should be part of every pediatrician's medical training.

"If you have an area that affects approximately one-half of patients," she said, "you would think that all pediatricians should know a little about it."

Some that show promise

Although parents looking for solid research on pediatric supplements can come up empty-handed, doctors and alternative experts say some products have been found to be slightly to significantly effective in children in double-blind, randomized clinical trials.

Among them:

• Peppermint oil, for irritable bowel syndrome: After two weeks of capsules, 75% of 42 children ages 8-17 taking peppermint had reduced severity of pain. (Journal of Pediatrics, 2001)
• Fennel seed oil, for colic: In a group of 125 infants age 2 weeks to 12 weeks, those who took fennel seed oil showed a significant improvement in symptoms over those who took a placebo. (Alternative Therapies in Health and Medicine, 2003)
• Chamomile, for colic: Prepared as an herbal tea, it eliminated colic in 57% of 33 infants, whereas a placebo helped only 26% of 35 infants. (Journal of Pediatrics, 1993)
• Otikon Otic solution (a naturopathic extract containing Allium sativum, Verbascum thapsus, Calendula flores), for pain from an ear infection: Researchers found some lessening of ear pain in a group of 103 healthy children ages 6 to18 who took an herbal extract, with no side effects. (Archives of Pediatrics, 2001).

— Hilary E. MacGregor