Transcript No Slide Title

Use of complementary and
alternative medicines in children
Too important to ignore
Alissa Lim, Trainee Research Fellow
Annette Webb, Paediatric Registrar
Gill Kainey, RN, Clinical Support Services
Kaye Hynes, Senior Pharmacist
Noel Cranswick, Clinical Pharmacology
Angela Mackenzie, Paediatrician
Elizabeth Kennedy, Lawyer
Liza Newby, Health Policy Consultant
Mike South, Paediatrician
Complementary
Natural
Unproven
Holistic
Whacky
Integrative
Dangerous
Healing
Fraudulent
Alternative
I thought I should
mention doctor, that we
have been giving him a
Chinese herbal tonic to
build up his strength for
the operation next month.
That’s OK isn’t it?
The herbalist said we
must keep giving it to him
while he is in hospital for
the operation.
Can we do that?
I won’t be able to stay in
overnight with him
because I will need to be
home for the other kids.
Would it be OK for the
nurses to give him the
tonic when I’m not there?
Aims
• Present our own research
• Present a new RCH policy and
associated guidelines regarding CAM
usage for RCH inpatients
Complementary and
alternative medicine (CAM)
Complementary or Alternative Medicine (CAM) is a
broad domain of healing resources that
encompasses all health systems, modalities and
practices and their accompanying theories and
beliefs, other than those intrinsic to the politically
dominant health system of a particular society.
Cochrane Collaboration
Examples
Medicines
Herbal therapies
Homeopathy
Megavitamins
Naturopathy
Traditional Chinese Medicine
Other therapies
Acupuncture
Chiropractic
Ayurveda
Aromatherapy
Hypnotherapy
Reiki
Kinesiology
Moxibustion
Reflexology
Complementary and
alternative medicine (CAM)
Diverse opinion amongst orthodox health
professionals regarding role of CAM in health care.
(Mirrored in our group)
Complementary and
alternative medicine (CAM)
• It is likely that some forms of CAM are good
therapies with important potential roles in health
care.
• Some will be ineffective but harmless.
• Others will be dangerous.
• Every CAM has its own combination of risk &
benefit.
(Just like orthodox therapies)
Alternative therapist faces questions after boy dies
The Royal Children's Hospital has asked the Justice
Department to investigate an alternative health practitioner
who it believes advised the family of a teenage boy with
curable cancer to stop chemotherapy.
The Age 21/09/2002
Special issues regarding
CAM use in children
• Child not competent to make own
decisions
• Consequences of parental choice
• ?Balance of parental autonomy and
child’s wellbeing
• Our responsibilities as health
professionals
Non-medicine CAMs
Consider individually
RCH CAM Research
Alissa Lim, Trainee Research Fellow
Noel Cranswick, Clinical Pharmacologist
Sue Skull, Clinical Epidemiologist
Mike South, Paediatrician
CAM use in the
Community
• Cross-sectional survey
– Self-administered questionnaires
– Random sample of 30 primary schools
– Medication use in preceding two weeks
– 1534 questionnaires
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CAM use in the
Community
Types of CAM
20%
15%
10%
5%
0%
CAM use in the
Community
50%
Reasons for Use
40%
30%
20%
10%
0%
URTI
General
Health
Skin
Behaviour
CAM use in the
Community
Source of CAM
60%
50%
40%
30%
20%
10%
0%
Self Initiated Naturopath
Pharmacy Other CAM
/Shop
practitioners
Doctor
RCH survey of CAM use
• A cross-sectional survey of inpatient
and outpatients groups
– Questionnaire by face-to-face interview
– CAM use in the preceding 12 months
– 503 patients surveyed
• 101 inpatients and 402 outpatients (general
paediatric, gastroenterology, thoracic, diabetes)
RCH survey of CAM use
60%
CAM Use
50%
40%
30%
20%
10%
0%
Total CAM
Medicinal
CAM
Medicinal Non-medicinal
CAM (exclude
CAM
vitamins only)
RCH survey of CAM use
Types of Medicinal CAM
20%
15%
10%
5%
0%
Multi
vitamins
Vitamin C
Echinacea
Other
Herbal
Homeopathic
RCH survey of CAM use
35%
Reasons for CAM Use
30%
25%
20%
15%
10%
5%
0%
General
Health
URTI
Dietary
Supplement
Skin
GIT
RCH survey of CAM use
Had not told
doctor
RCH survey of CAM use
• Inpatient group:
– 22% had used medicinal CAM in last
month
– 2 patients (9%) documented
– partial documentation only
CAM Adverse Events
• Surveillance Study via Australian
Paediatric Surveillance Unit (APSU)
• 29 reports over 20 months
(January 2001 to September 2002)
• Severity :
mild to severe
2 fatality
CAM Adverse Events
Report Types:
A.
Adverse events associated with the
use of medicinal CAM
B.
Adverse events associated with
failure to use conventional therapy
CAM Adverse Events
CAM
ADVERSE EVENT
Valerian
Constipation
Colloidal silver
Argyria
Ginkgo and Ginseng
Prolonged bleeding time
*Crushed Pearl
Acidosis
*“Infacalm” drops
overdose
Hypoglycaemia,
drowsiness, tachycardia
Daily IM vitamin injections
Left sciatic neuropraxia and
ongoing leg pain
Homeopathic treatment
and diet restriction
Malnutrition and sepsis
* Mechanism unknown
RCH CAM Research
• Common in the community
• Very common in patients attending RCH
½ in last 12 months, ¼ in last month
• Evidence of potential adverse effects or
interactions.
• Families often don’t “tell”
RCH CAM Group
DUC Subcommittee
•
•
•
•
Policy
Guidelines
Resource documents
Drug Information Resources
Issues
• Acknowledge CAM is used for children
and get it “out in the open”
• Safety
• Parental choice
• Legal
• Ethical
• Documentation
• Practical issues
• Ward safety
RCH CAM Policy
RCH CAM Guidelines
General guideline for RCH Inpatients
Ask all patients about
current use of CAM
Consider implications of CAM use
(effects, interactions etc)
for patient's condition
Ring Drug Info - 9345 5208
Does parent wish to use
CAM while child in
hospital?
No
Discuss use of
CAM outside hospital
Yes
Provide parent version
of CAM policy
No
Is the medicine eligible for approval
It must have an AustL or AustR number
No
Ring Drug Info - 9345 5208
Yes
Does the responsible
consultant approve use of
CAM for this patient?
Do parents insist on CAM
usage in hospital?
? Child at risk
No
Yes
Yes
Record details in Medical Record
Parents to sign the With Medical
Approval section of Usage Statement
(file in record)
Parent to supply CAM
CAM record chart initiated
CAM to be stored in ward drug
cupboard
Parents to administer and
record on CAM record chart
Record details in Medical Record
Parents to sign the Against Medical
Advice section of Usage Statement
(file in record)
Use of CAM in exceptional circumstances where it is
inappropriate/impossible for parents to
administer it themselves.
Examples
Patient in ICU
Parents unavailable to adminsister CAM themselves and wish hospital staff to
do so in their absence
Is the medicine eligible for approval
It must have an AustL or AustR
number
Ring Drug Info - 9345 5208
No
Yes
Does the responsible consultant
approve use of CAM for this
patient?
No
Medicine
NOT to be administered
by hospital staff
Yes
Is the patients consultant prepared
to take full responsibility for the
prescription of the medicine?
No
Yes
Are the nursing staff prepared to
administer the medicine?
No
Yes
Medicine to be prescribed on usual
prescribed drug section of medication
chart.
Nurses to administer and record doses
as for any other prescribed medication
Record details in Medical Record
Parents to sign Usage Statement
Under no circumstances may hospital staff administer CAM to a patient outside this
guideline even if an Use Against Medical Advice Statement has been signed
Working with families around
CAM
• Whatever your views on CAM - it cannot be
ignored, and it will not go away.
• If the parents of children you care for don’t tell
about CAM use - there is the potential for an
adverse outcome.
• Presenting an antagonistic attitude is unlikely to
be helpful.
• Presenting an open-minded, non-judgmental
attitude is likely to improve trust and
understanding.
Resources
www.rch.org.au/genmed/camguidelines.htm
The Drug Information Service – ext 5208.