EXECUTIVE SUMMARY

Complementary and Alternative Medicine (CAM)
Therapies in Pediatric Practices

This survey was initiated by the Task Force on Complementary and Alternative Medicine to assess the knowledge, attitudes and behaviors of AAP members regarding use of complementary and alternative (CAM) therapies in their practice. The survey explored pediatricians' practices and beliefs surrounding complementary medicine and alternative therapies, including screening on patients' use of CAM, beliefs about the effectiveness of CAM, knowledge about and recommendations/referrals for CAM therapies, as well as personal use of CAM. This survey will be used to assess the degree to which pediatricians are aware of their patients' interest in and use of CAM and the degree to which pediatricians have integrated complementary medicine and alternative therapies into their practice. Findings will be used to guide future efforts in developing educational programs in this area.

Periodic Survey #49 was an eight-page self-administered questionnaire sent to 1,607active United States members from July through November 2001. After an original and five follow-up mailings a total of 856 completed questionnaires were received for a response rate of 53.3%. Analyses are based on 745 pediatricians (87% of all respondents) who provide direct patient care.

Screening for CAM Use
Eighty-seven percent of pediatricians had at least one inquiry from patients or parents about a complementary or alternative therapy during the three months prior to the survey; 12.9% had no such inquiries. The most common inquiries were about herbs such as echinacea or St. Johns wort (67% of pediatricians reported such inquiries), dietary supplements, such as melatonin, fish oil, megavitamins (64%), chiropractic (59%) and special diets such as vegetarian or macrobiotic (46%).

When taking a patient history or prescribing medication, nearly all pediatricians ask their patients about use of prescription medications and over-the-counter-medications such as acetaminophen (89.1% and 81.8% of pediatricians, respectively, ask more than 75% of their patients about these medications). However, few pediatricians ask their patients about use of any form of CAM. About 1 in 5 pediatricians ask about herbal therapies (20.2%), special diets (17.5%) or dietary supplements (17.3%), but the majority of pediatricians do not ask their patients about any other form of CAM.

Recommendations/Referrals for CAM Therapies: 3 Scenarios
Nearly all pediatricians (91.9%) recommend antihistamines or decongestants for recurrent upper respiratory infection in a 3-year old and 83% say they may also test for allergies. In addition, most also recommend environmental strategies such as use of an air filter and/or avoidance of tobacco smoke (93.0%) and avoiding crowed day care settings (83.6%). More than half (58.0%) say they would usually or occasionally give nutritional recommendations such as chicken soup or avoiding milk, and 30.8% would recommend Eucalyptus oil in a vaporizer or a VAPO-bath. Pediatricians less commonly recommend, even as adjunctive therapies, any other CAM therapy.

Nearly all pediatricians follow standard guidelines for medical management of a 15-year old with moderately severe asthma, ie, 98.0% recommend beta-agonists and 98.3% recommend daily anti-inflammatory medications. Ninety-two percent also recommend environmental strategies such as reducing exposure to allergens and tobacco smoke. Most pediatricians recommend exercise such as Yoga or swimming (55.1%) to complement standard biomedical treatment, and 18.4% also recommend hypnosis or relaxation therapy. Fewer than 10% recommend any other CAM therapy for this condition.

Nearly all pediatricians (97.2%) follow standard guidelines for management of attention deficit hyperactivity disorder, ie, recommend medications such as Ritalin, Cylert, etc. In addition, most recommend environmental strategies such as more structure and one-on-one attention (85.6%) and an individual learning plan and tutoring (85.3%). More than half of pediatricians (57.0% would also recommend psychotherapy. About one-fourth would recommend, as adjunctive therapies caffeine (29.5%), Yoga (24.5), or mind-body therapies such as hypnosis, relaxation or distraction (21.5). Fewer than 5%of pediatricians recommend other forms of CAM.

Attitudes Toward CAM
One-third of pediatricians (34.9%) say they or their families used some type of CAM therapy during the 12 months prior to the survey; 66.0% reported no use of CAM. Seven out of 10 pediatricians (70.3%) who say they used CAM therapies during the past year reported using a massage therapist, 21.0% say they sought care from a chiropractor, 13.5% say they consulted a spiritual or religious healer and 13.1% saw an acupuncturist.

Most pediatricians (72.8%) agree they should provide patients with information about all potential treatment options. More than half (53.8%) think they should consider nontraditional therapies when treating patients; however, 48.1% think that doing so may make them susceptible to medical liability claims (and 31% are unsure). Nearly 40% of pediatricians say they are comfortable discussing CAM therapies with patients and are confident in their ability to manage/coordinate the care of patients who are also seeing nonmedical providers; however a large proportion is unsure (26% and 28%, respectively). Pediatricians are fairly evenly divided as to whether they would recommend a CAM therapy considered safe but of untested efficacy for chronic life-threatening conditions (37.1% agree, 31.6% disagree and 31.3% are unsure) or acute self-limiting conditions (32.5% agree, 32.0% disagree and 35.6% are unsure).

Seventy percent of pediatricians say they have patients who use CAM therapies. Among these pediatricians, most do not think use of CAM typically interferes with standard medical care (37.7% say seldom/never, 44.4% occasionally), causes delay in seeking standard medical care (21%, 51.1%), or impairs doctor-patient communication (49.4%, 36.0%). h of pediatricians think use of CAM therapies often increases the risks of additional side effects (27.9%) and about half (46.8%) think it occasionally increases such risks. While more than half of pediatricians (56.9%) do not think CAM therapies reduce the side effects of standard medications, 18.3% of pediatricians think they often or occasionally do so and a large proportion, 24.7%, are unsure. Most pediatricians (55.9%) think use of CAM therapies does not decrease overall health care costs, however, 17.9% say it often or occasionally decreases such costs and 26.2% are unsure about its effect on health care costs.

Information Needs Regarding CAM Therapies
In general, most pediatricians report they have little or no knowledge of complementary or alternative medicine therapies. However, 3 out 10 pediatricians express at least moderate knowledge about nutritional therapies, dietary/nutritional supplements, therapeutic exercise, and massage therapy. About one-fifth of pediatricians say they are knowledgeable about chiropractic, herbal remedies, spiritual healing, and mind-body therapies such as hypnosis, relaxation or biofeedback. Fewer pediatricians report any substantial knowledge about other forms of CAM.

Interest is high among pediatricians in receiving information about all areas of CAM therapy. Three-fourths of pediatricians indicate they would like more information on dietary supplements, herbal remedies and nutritional therapies. Seventy percent expressed interest in therapeutic exercise, about 60% are interested in information on various mind-body therapies, acupuncture/acupressure and massage therapy. About half of pediatricians want to know more about homeopathy, Therapeutic Touch, environmental therapies, chiropractic and spiritual healing.