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
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
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
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.
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
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;
.05 were considered significant. Confidence intervals were
calculated for the difference between 2 proportions, and those that
excluded zero were considered significant (15).
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
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.
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.
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
(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
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
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
. 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.
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
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).
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.
- Adams PF, Marano M.
Current Estimates From the National Health Interview Survey,
Hyattsville, Md: US Dept of Health and Human Services, National
Center for Health Statistics; 1994. Vital and Health Statistics,
Series 10, No. 94.
- Bernard-Bonnin AC, Stachenko S, Bonin D, Charette C, Rousseau
E. Self-management teaching programs and morbidity of pediatric
asthma: a meta-analysis.
J Allergy Clin Immunol.
- Pachter LM. Folk illness beliefs and behaviors and their
implications for health care delivery.
- Chesney AP, Thompson BL, Guevara A, Vela A, Schottstaedt MF.
Mexican-American folk medicine: implications for the family
J Fam Pract
- Brookins GK. Culture, ethnicity, and bicultural competence:
implications for children with chronic illness and disability.
- Pachter LM, Weller SC. Acculturation and compliance with
J Dev Behav Pediatr.
- Patterson JM, Blum RW. A conference of culture and chronic
illness in childhood: conference summary.
- Korsch BM, Freemon B, Negrete VF. Practical implications of
doctor-patient interaction analysis for pediatric practice.
Am J Dis Child.
- DiMatteo MR, Hays RD, Prince LM. Relationship of physicians'
nonverbal communication skills to patient satisfaction,
appointment noncompliance, and physician workload.
- Eisenberg DM, Kessler RC, Foster C, Norlock FE, Calkins DR,
Delbanco TL. Unconventional medicine in the United States,
prevalence, costs, and patterns of use.
N Engl J Med
- Spigelblatt L, Laine-Ammara G, Pless IB, Guyver A. The use of
alternative medicine by children.
- Pachter LM, Cloutier MM, Bernstein BA. Ethnomedical (folk)
remedies for childhood asthma in a mainland Puerto Rican
Arch Pediatr Adolesc Med
- Risser AL, Mazur LJ. Use of folk remedies in a Hispanic
Arch Pediatr Adolesc Med.
- Marsh WW, Hentges K. Mexican folk remedies and conventional
Am Fam Physician
- Rosner B.
Fundamentals of Biostatistics.
2nd ed. Boston, Mass: Duxbury Press; 1986.
- Furnham A, Smith C. Choosing alternative medicine: a
comparison of the beliefs of patients visiting a general
practitioner and a homeopath.
Soc Sci Med
- Spigelblatt L. Alternative medicine: a pediatric conundrum.
- Snow LF. Traditional health beliefs and practices among lower
class black Americans.
West J Med
- Global Strategy for Asthma Management and Prevention
. Bethesda, Md: National Institutes of Health; 1993. National
Heart Lung and Blood Institute/World Health Organization Workshop
- Kemper KJ. Seven herbs every pediatrician should know.
- Goldfrank L, Lewin N, Flomenbaum N, Howland MA. The
pernicious panacea: herbal medicine.
- Schoneberger D. The influence of immune-stimulating effects
of pressed juice from Echinacea purpurea on the course and
severity of colds: results of a double-blind study.
- Schwartz J, Weiss ST. Caffeine intake and asthma symptoms.
- Kang B. Study on cockroach antigen as a probable causative
agent in bronchial asthma.
J Allergy Clin Immunol
- Bakerink JA, Gospe SM Jr, Dimand RJ, Eldridge MW. Multiple
organ failure after ingestion of pennyroyal oil from herbal tea
in two infants.
- Marin BV, Padilla AM, De La Rocha C. Utilization of tradition
and nontraditional sources of health care among Hispanics.
Hispanic J Behavior Sci.
- Field T, Henteleff T, Hernandez-Reif M, et al. Children with
asthma have improved pulmonary functions after massage therapy.
- American Academy of Pediatrics Committee on Drugs. Camphor
revisited: focus on toxicity.
- Nielson NH, Bronfort G, Bendix T, Madsen F, Weeke B. Chronic
asthma and chiropractic spinal manipulation: a randomized
Clin Exp Allergy
- Reilly D, Taylor MA, Beattie NG, et al. Is evidence for
- Yu DY, Lee SP. Effect of acupuncture on bronchial asthma.
Clin Sci Mol Med.
- Virsik K, Kristufek D, Bangha O, Urban S. The effect of
acupuncture on pulmonary function in bronchial asthma.
Prog Resp Res
- Fung KP, Chow OK, So SY. Attenuation of exercise-induced
asthma by acupuncture.
- Jobst KA. A critical analysis of acupuncture in pulmonary
disease: efficacy and safety of the acupuncture needle.
J Altern Complement Med
- Bodner G, Topilsky M, Greif J. Pneumothorax as a complication
of acupuncture in the treatment of bronchial asthma.
Use of alternative and complementary therapies, by ethnicity.
|Massage (VapoRub, pig lard with camphor,
skunk lard, fish oil)
* Significantly different from other groups (