Hope springs eternal in the human breast. It is understandable that families resort to complementary and alternative therapies (CAM) when and where conventional medicine appears to offer little. Gastro-oesophageal reflux and constipation are generally regarded as self-limiting conditions usually of nuisance value by gastroenterologists, and the therapies prescribed are palliative and served up with lashings of reassurance. In this context, it is both natural and not surprising that parents, especially mothers, desire to speed things up and seek assistance elsewhere. Complementary medicine has been with us since primitive times and despite the railings of doctors, community acceptance of these therapies has never been more robust.
In this issue of the Journal Andrew Day describes the use of complementary and alternative therapies and probiotic agents in 92 children attending gastroenterology outpatients at Sydney Children's Hospital.1 A questionnaire explored the use of five specific therapies and asked about whether patients had been receiving others. Thirty-six per cent of children were either using a complementary therapy or had recently used a complementary therapy. Given that 78% of parents said they were happy to administer alternative therapies if they thought benefit would result, it is quite likely that the lifetime exposure to CAM in these children is much higher than the 36% reported. These figures are very similar to the 41% reported to use CAM in an Anglo-American study in paediatric inflammatory bowel disease clinics.2 In this study, only 6% used probiotics, as opposed to 22.3% in the Australian study. This difference is surprising, particularly as probiotics have been reported to be beneficial in inflammatory bowel disease.3 The three previous studies of CAM in Australian children have all been small and disease-specific. Studies in asthmatic children and oncology patients in Adelaide showed a 55% and 46% prevalence of use, respectively, and a study of attention deficit hyperactivity disorder (ADHD) children from Western Australia showed a usage prevalence of 64%.4−6 These figures are similar to those shown in the adult population in the South Australian Health Omnibus Survey, where 48.5% of South Australians over the age of 15 had used at least one CAM.7
Overseas studies, including a large outpatient study in Quebec, an inpatient study in New Zealand and a random population study in south-west England, have shown usage prevalences of 11%, 29% and 18%, respectively.8−10 Although there are marked differences in study design, it would appear that Australians of all ages resort to CAM frequently. The prevalence of CAM use reported in Australian studies far outstrips that reported elsewhere. The differences in prevalence are quite likely to result from differences in the survey vehicle, that is, the more therapies you ask about the more likely you are to uncover use of the same. For example, we have recently surveyed 902 parents and discovered that 91 therapies were administered to the cohort (unpubl. data). We asked specifically about 18 therapies and in an en face interview asked them to provide details of other therapies. Andrew Day's study and the New Zealand and Quebec studies asked about only a few specific therapies. Therefore, the differences reported are probably apparent rather than real.
What else can be gleaned from the literature? Most of the interesting phenomena, such as gender differences, family use, use segregated on socioeconomic lines, sources of information about CAM, perceived benefits of various CAM and harmful effects and side-effects, are either not explored or explored in a rudimentary fashion in most studies. Most consumers are satisfied. When closely examined, the purported benefits are seldom condition-specific, but are usually holistic, such as improved mood, improved sleep, better appetite and other difficult-to-quantify effects. Harm seldom results. Most CAM practitioners are careful and often potentially harmful medicines are prescribed in homeopathic amounts. After all, you don’t want to harm the goose that lays the golden eggs.
Most parents obtain information about CAM either through the media (e.g. magazines) or by word of mouth. They seldom discuss it with doctors. This is usually because they regard the therapy as a part of normal life and it does not occur to them to volunteer this information. Only in a minority of cases is the information not volunteered because parents suspect the doctor will either not understand or be derisive. Then again, doctors and paediatricians seldom, if ever, inquire about the use of alternative medicines,11 despite some well-publicized disasters, such as bleeding after Gingko biloba extracts ingested prior to surgery,12 liver dysfunction after comfrey13 and kombucha mushroom teas,14 and other similar episodes. Awareness might be increasing. Interestingly, I have noted that St Andrew's private hospital in Adelaide now inquires about herbal medicines on its pre-admission form.
How can we move ahead? Future studies should explore phenomenology in much greater detail. On a practical note, individual practitioners should understand that if they don’t ask about specific therapies they will not know about their patients’ involvement with such therapies. This may entail an explanation to the parents in simple terms, as they may have a different concept of a therapy than you as their doctor has. I think it is a mistake to adopt a judgemental attitude towards alternative therapies and dismiss them out of hand. After all Cinchona (quinine), Coca (cocaine), Willowbark (salicylates) and Foxglove (digitalis) were alternative therapies before curiosity gripped Victorian alkaloid chemists. A rational inclusive approach is more likely to be fruitful. Most CAM practitioners are not disreputable shamans who are intent on duping the gullible public. Most of them believe that they are helping their customers. I have on occasion enlisted the help of naturopaths and herbalists to modify the belief systems of mutual patients. For example, I have been able to tailor the antioxidant intake of a patient with chronic recurrent pancreatitis by talking to her naturopath.
Along with tolerance, we should foster a healthy scepticism. Most CAM therapies are not subject to the same scrutiny that conventional therapies are, and indeed when they are subjected to scrutiny, they seldom measure up. Chiropractic medicine has been shown to add nothing to asthma management,15 and is only marginally better and much more costly than an educational booklet for patients with low back pain.16 Complementary and alternative therapy practitioners should be encouraged to subject the products they survey to proof and rigour. This is particularly important as they lobby for inclusion in Medicare and private health fund benefits. Blind acceptance of claims of efficacy is not a responsible way to manage the scarce health dollar.
I believe that CAM should be taught at medical schools. CAM costs Australian families billions of dollars a year,7 and on fiscal grounds alone it behoves doctors to understand CAM therapies. I don’t think many doctors will enthusiastically embrace the outlandish and bizarre and, like it or not, CAM therapies are here to stay. The University of Queensland is a pathfinder in this regard and has set up a centre for the study of complementary medicine within its Faculty of Health Science.
If one can distil a single lesson from the use of CAM therapies, it is probably that most people have a strong independent desire for self-help for themselves and their dependants, and that we as medical practitioners should see this as heartening. We should guide, not judge.