Use of Complementary and Alternative Therapies for Pediatric Asthma

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Journal Article -- June 2001  

By Lynnette J. Mazur, MD, MPH; Lisa de Ybarrondo, MD; Jamey Miller, RN; Giuseppe Colasurdo, MD  

From the University of Texas-Houston Medical School, Department of Pediatrics. Send reprint requests to Lynnette J. Mazur, MD, MPH, Department of Pediatrics, The University of Texas-Houston Medical School, 6431 Fannin, Ste 3.138, Houston, TX 77030.  

This survey of 48 multicultural parents of children with asthma identifies and compares alternative and complementary treatments used for asthma, and compares any potentially effective or harmful effects. Thirty-nine (81%) of the parents used at least one form of alternative or complementary therapy to treat their child's asthma. Nontraditional therapies included prayer, over-the-counter medications, herbal teas, vitamins, and massage. African-American parents were more likely to rely on prayer, and Hispanic parents were more likely to use herbal and massage therapies. Use of over-the-counter medications and vitamins was similar among groups. Three herbal remedies were potentially toxic: lobelia, possible pennyroyal mint, and tree tea oil. Medical histories for all patients should include inquiries into the use of alternative therapies.

Introduction  

Asthma is the most common chronic disease of childhood (1). Despite improvements in the knowledge and treatment of asthma, its morbidity and mortality continue to increase. Some authors suggest that the focus on intermediate outcomes such as behavior be incorporated into educational programs (2). Health behavior and, ultimately, compliance may also be enhanced through acknowledgment and acceptance of patients' beliefs and cultural practices (3-9).

Visits to unconventional medical practitioners exceed the number of visits to primary care physicians, and expenditures for these therapies are estimated at $14 billion per year (10). Use of alternative therapies is highest among those with asthma and other chronic illnesses (11,12). Understanding these practices and the reasons for their use is necessary for us to improve the quality of physician-patient communication as well as to identify potentially harmful effects. Although many studies describe the use of alternative and complementary therapies in the Hispanic population (4,13,14), few examine their use in other ethnic groups. The purpose of this study was to identify and compare alternative and complementary treatments used for asthma in a multicultural group of patients and to identify those treatments with potentially beneficial or harmful effects.

Methods  

The study was conducted at the Asthma and Pulmonary Center at Memorial Hermann Children's Hospital in Houston, Tex. The Committee for the Protection of Human Subjects gave approval to conduct the study, and each patient's caregiver gave written informed consent to participate.

Between September 1996 and December 1997, we interviewed a convenience sample of caregivers during clinic on one half-day each week. All patients had persistent moderate-to-severe asthma and were referred from their primary care physicians for evaluation and treatment. All parents and patients were eligible for the study. Because of time limitations and lack of an established rapport at the first clinic visit, parents were interviewed on follow-up visits. A structured, 15-minute interview was conducted by one of two pediatricians (LJM, LdY) or by the clinic coordinator (JM). Demographic data, immigration status, the patient's asthma history, parental perception of the cause of asthma, and use of prescribed and alternative and complementary therapies were documented. Descriptive statistics calculated for the entire group included ethnicity. Differences between ethnic groups were compared by a 2-tailed Fisher exact test; P values < .05 were considered significant. Confidence intervals were calculated for the difference between 2 proportions, and those that excluded zero were considered significant (15).

Results  

Forty-eight parents were interviewed: 21 (44%) were African-American; 11 (23%) were Hispanic (10 had immigrated from Mexico and 1 from El Salvador); 10 (21%) were Caucasian; and 6 (12%) were "other." Thirty-seven (77%) mothers, 35 (73%) fathers, and all of the children were born in the United States. Twenty-nine (60%) of the children were male, and the overall mean age was 7.5 years (range, 6 months to 19 years).

Responses to "What do you think caused your child's asthma?" included heredity, 17 (35%); weather, 7 (14%); prior infection, 4 (8%); and allergies, 3 (6%). Other causes included prematurity, cold foods, moving to the United States, exposure to rain, weak lungs, prolonged antibiotic use, intubation, and gastroesophageal reflux. Some parents reported more than a single cause, and 10 parents had no explanatory model.

Thirty-nine (81%) parents reported using either or both alternative and complementary therapies, and all were used concurrently with their prescribed medications. Although not specifically asked about alternative therapies during their first visit, parents were questioned about current and past therapies; none of the patients voluntarily reported using alternative or complementary therapies. Overall, however, 75% of the parents prayed for help, 38% used over-the-counter medications, 21% used herbal remedies, 21% used vitamins, and 15% used chest massage. The most common therapies used by the various ethnic groups are shown in the Table . Use of prayer, herbs, and massage therapy showed significant differences among groups. When 95% confidence intervals were calculated for the differences between proportions using various therapies, the use of herbs and of massage therapy both differed significantly in comparisons between Hispanic patients and all other patients. For herbs, the 95% CI was 0.14-0.84; for massage, it was 0.06-0.75.

Nine herbal preparations were used: chamomile, coffee, echinacea, eucalyptus, goldenseal, lobelia, mint, tea, and tree tea oil. Chamomile, coffee, echinacea, lobelia, mint, and tea were prepared as beverages. Echinacea, goldenseal, mint, and tree tea oil were oral solutions taken by the dropperful. Two parents used aerosolized eucalyptus: one parent added it to the nebulizer with albuterol or cromolyn or both, and the other placed it in a vaporizer. Eucalyptus was used also for chest massage.

Six (12%) parents consulted with nonphysician practitioners including acupuncturists, 2; chiropractors, 2; homeopaths, 1; naturopaths, 1; and an iridologist, 1. Other nontraditional therapies were used. Nine parents used vitamins B and C with a daily multivitamin as adjunctive therapy. One Asian-American parent reported using megadoses of a Chinese vitamin complex when the child's eczema flared up. Three parents believed that a dog (two Chihuahuas and one Chow/Labrador mix) would be beneficial; one of these parents believed that the child would be cured when the pet acquired the child's asthma. Two mothers acted on the belief that their children would outgrow asthma: one marked her child's height on a tree with a nail with the belief that the symptoms would resolve when the child passed the mark; the other had a similar belief but marked the child's height with a lima bean and buried the bean next to the tree. One patient cut a lock of his hair, cut a hole in an oak tree, and periodically sniffed the hair for help. This same patient's grandmother blew cigarette smoke over the top of his head whenever he had an exacerbation. Upon recommendation from a naturopath, one mother changed her child's diet by eliminating red meat and cow's milk for 1 year. One patient slept on a magnetic mattress cover and wore a magnet over his chest to improve his breathing.

Discussion  

Our study is one of a few to place in a cross-cultural context the issue of alternative and complementary therapies. Often, studies on alternative medicine are conducted on cultural minority groups and may give the impression that only minority populations use alternative medicines.

Reasons why parents choose alternative therapies may include attraction to therapists recommended by family or friends, a desire for a more holistic approach, their ethnic and cultural background, beliefs that alternative therapies are more natural, and the desire for more active participation in the treatment. Also, caregivers may be dissatisfied with conventional methods or be concerned about the possible side effects of traditional therapies, fear new technologies, or have financial constraints (16,17). Although our study was small, significant differences were noted in the use of herbs and massage therapy in Hispanic patients.

Prayer
In our study, 95% of the African-American mothers relied on prayer for treatment of their child's asthma. Both individual and group prayer were reported. In another study, 90% of the patients stated that religion shaped many of their ideas about health (18). Illness was considered a result of sinning; therefore, a reliance on prayer was a logical outcome. In a survey of ethnomedical remedies for asthma, 73% of Puerto Rican mothers prayed to God and 12%, to the saints (12). Although our study showed that African-Americans were more likely to pray for their children's asthma, many Hispanics (64%) and Caucasians (60%) prayed also. The same study also reported similar family-held explanatory models for asthma such as heredity, weak lungs, and cigarette smoke (18).

Potentially beneficial herbs
Some modern treatments for asthma have their origins in folk remedies. For example, adrenergic drugs, atropine, and sodium cromoglycate are derived from cromone khellin found in the West Asian plant Ammi visnaga (19). Teas from the chamomile and echinacea flowers have anti-inflammatory properties. Chamazulene, one of the active components of chamomile, is a leukotriene inhibitor (20) that is used in the treatment of asthma. Anaphylaxis may occur rarely in patients who are allergic to members of the Compositae family (ragweed and chrysanthemum) (20). Cases of botulism have been reported also (21). A randomized trial with echinacea showed a significant reduction in the number of upper respiratory infections, a well-known trigger for asthma exacerbations (22). Echinacea also has antiviral effects in vitro against influenza, and no adverse effects have been reported.

Caffeine, a well-known bronchodilator, has been used for both prevention and treatment of asthma (23). Potential adverse reactions that may be counterproductive include insomnia and gastroesophageal reflux. The stimulant chemicals in tea, caffeine, theobromine, and theophylline are also bronchodilators, but large doses have the same effects as coffee (23).

The Food and Drug Administration (FDA) has approved eucalyptus as a cold and influenza remedy. In our study, eucalyptus was used for massage therapy (Vicks VapoRub) and as a cough lozenge. No studies have evaluated its effectiveness for the treatment of asthma; however, it repels cockroaches, a well-known asthma trigger (24).

Potentially harmful herbs
Goldenseal has been studied for the treatment of upper respiratory infections, diarrhea, conjunctivitis, otitis media, and eczema but not for asthma (19). Hydrazine, one of its active ingredients, causes peripheral vasoconstriction and hypertension. Other adverse reactions include irritation of the oropharynx, nausea, vomiting, and diarrhea (19).

Lobelia, also known as "Indian tobacco" and "asthma weed," is poisonous. Its toxicity resembles that produced by nicotine: nausea, vomiting, diarrhea, abdominal pain, mental confusion, muscle weakness, hypotension, and difficulty breathing. Lobelia was once used as a central nervous system stimulant in the treatment of respiratory depression (21).

Homegrown mint was used by one of our patients. The pennyroyal mint plant is poisonous and is difficult to differentiate from spearmint and peppermint. Ingestion of pennyroyal can result in liver failure and death (25). Peppermint is an FDA-approved remedy for the common cold, primarily because of its decongestant action. The active ingredient, menthol, is also present in Mentholatum and Vicks VapoRub, which are used for massage and inhalation therapy. However, pure menthol can be fatal if ingested, and pure peppermint oil can cause cardiac dysrhythmias.

Not to be confused with tea, tree tea oil is derived from the leaves of the Australian tree Melaleuca alternifolia . The leaves contain phenol, a potent antibacterial, which can be used in the topical treatment of acne and fungal infections but has no known benefit in the treatment of asthma. As little as 1 teaspoon can cause coma (19).

Since herbs are considered neither food nor drug, the FDA cannot effectively regulate their use. The Dietary Supplement Health and Education Act of 1994 permits herbs and other plant-based remedies to be sold as dietary supplements but with no efficacy or safety requirements. To remove an herbal product from the market, the FDA is required to prove that it is unsafe. Although some of the herbal remedies have approval, home preparations have varying concentrations. They may also be used in unapproved forms.

Massage
The use of massage therapy for asthma was very common in our Hispanic patients as compared with 20% in a Los Angeles Hispanic group and 93% in a New York Hispanic group (26,27). The former study was not limited to patients with asthma and the latter included only Puerto Rican patients. This suggests that differences may exist even within the Hispanic community. In one study, children who received massage therapy before bedtime had improved pulmonary functions: a 24% increase in the forced vital capacity and a 57% increase in the forced expiratory flow (27). Because emotional extremes may trigger some exacerbations, the same study examined anxiety levels by measuring salivary cortisol levels and showed decreased levels after massage. Identification of the oils used for massage is important. One of our patients used a concentrated camphor-based lotion that could have been fatal if ingested (28). The American Academy of Pediatrics recommends that over-the-counter products contain not more than 11% camphor (28).

Nonphysician visits
A Canadian study showed that 36% of patients had visited a chiropractor; 25%, a homeopath; 11.5%, an acupuncturist; and another 11.5%, a naturopath (11). Our lower percentages may result from differences in the patient populations or in the local availability of these practitioners.

Chiropractors believe that spinal manipulations remove interference with normal nerve tensions so that the body may heal itself. One study showed some effectiveness of chiropractic therapy for the treatment of asthma (29).

Homeopathy is based on the principle that a substance producing symptoms in a healthy person can cure the same symptom in a sick person when used in infinitesimally small doses. Serial dilutions of a substance are made until none of the original molecules remain. The interaction of the energy of the diluent and the patient's condition is curative (30). One double-blind, randomized controlled trial showed that homeopathy was effective in the treatment of asthma (30). However, some preparations have an alcohol base, and others contain potentially toxic amounts of arsenic and mercury (11,21).

Specific acupuncture methods include needles, shiatsu massage, heat (moxibustion), and lasers. Studies show that acupuncture has weak bronchodilatory effects but that complications such as pneumothorax needle breakage, cardiac tamponade, and hepatitis B and C may occur (31-35).

Conclusions  

The use of alternative and complementary therapies or both was very common in all our patients. Although most therapies are harmless, potential side effects and toxicities exist. If patients rely solely on nontraditional therapies, they may delay seeking help until severe symptoms are present, and morbidity and mortality may increase. To increase the awareness of nontraditional therapies for both clinician and patient, we suggest that inquiries into the use of alternative therapies become a routine part of the medical history for all patients.

References  

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Use of alternative and complementary therapies, by ethnicity.  

 

 
African American  
Hispanic  
Caucasian  
 
No. (%)  
No. (%)  
No. (%)  
Prayer (individual/group)
20 (95)*
7 (64)
6 (60)
Over-the-counter medications
7 (33)
2 (18)
4 (40)
Herbs
1 (5)
6 (54)*
1 (10)
Vitamins
3 (14)
2 (18)
4 (40)
Massage (VapoRub, pig lard with camphor, skunk lard, fish oil)
1 (5)
5 (46)*
1 (10)
Other
5 (24)
4 (36)
3 (30)

* Significantly different from other groups ( P <.05).


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