Use of Complementary and Alternative Medicine by
Children in Europe: Published Data and Expert PerspectivesThis section is compiled by Frank M. Painter, D.C.
Send all comments or additions to: Frankp@chiro.org
FROM: Complementary Therapies in Medicine 2013 (Apr); 21 Suppl 1: S34–47 ~ FULL TEXT
OPEN ACCESS Tycho J. Zuzak, Johanna Bonková, Domenico Careddu, Miklós Garami, Adamos Hadjipanayis, Janez Jazbec, Joyce Miller et. al.
Department of Pediatric Oncology and Hematology,
University Children's Hospital Essen,
Hufelandstr. 55, D-45147
Essen, Germany.INTRODUCTION: Few data document the use of complementary and alternative medicine (CAM) in Europe, with even fewer investigating use by children.
METHODS: A narrative, non-systematic review of CAM use in Europe was performed by combining data from published surveys with expert perspectives. Limitations created by a lack of representative studies, varying definitions of CAM use, and what qualifies as CAM in different countries was partially overcome by integrating local experts to summarise information available only in the national language and provide their perspectives about CAM availability, quality, use and popularity in their countries using a semi-structured questionnaire. Local and international published surveys were summarised, and the prevalence of CAM use was extrapolated.
RESULTS: Data from 20 European countries were available, representing 69% of the European population. Some data about CAM use by the general population were available for 90% of the examined countries, whereas peer-reviewed published surveys were available for only 60%. We extrapolated that 56% (range: 10-90%, adjusted for population size) of the European population in general had used CAM at least once in the past year. Surveys in CAM use by children were available for 55% of the investigated countries. The extrapolated prevalence of CAM use by children in Europe was 52% (range: 5-90%, adjusted for population size). Paediatric CAM experts reported an increasing awareness for and use of CAM in healthcare institutions.
CONCLUSION: This precursor for further surveys indicates that CAM appears to be popular not only among adults in Europe, but also for children. Development of a pan-European definition of CAM use and CAM therapies are required to achieve surveys comparable between European countries. Additionally, more research investigating the efficacy and potential adverse effects of CAM therapies is needed because of increasing CAM use by children in Europe.
KEYWORDS CAM; Prevalence; Europe; Child; Homeopathy; Herbal; Acupuncture; Anthroposophic
From the Full-Text Article:
Introduction
Complementary and alternative medicine (CAM) includes practices that are not an integral part of the conventional healthcare system, but are used by many patients to supplement their care. [1] Particularly patients in western industrial nations show an increasing interest in using CAM to treat acute and chronic diseases. [2–4] This rising interest includes both adults and children. [1, 5–7] Professional organisations, such as American Academy of Pediatrics and the WHO, have begun to collect and publish information about which types of traditional and complementary medicine are used by certain patient groups. [8, 9] Efforts to include education and training for CAM therapies in medical school programs and in healthcare institutions have also become popular in some European countries. [10, 11]
Europe covers approximately 10,180,000 km2 (3,930,000 sq. mi), consists of approximately 50 states and hosts a population of 731 million people. Europe is distinguished by its wide variety of languages, cultures and religions. This heterogeneity makes assessing CAM use and CAM training across Europe as a whole difficult. Exact numbers for the prevalence of CAM use in Europe are not available. Europe-wide surveys of CAM use by the public in general and not focussed on patients with a specific disease currently do not exist. The survey conducted by Molassiotis et al. gathered data for CAM use by cancer patients in 16 European countries using a descriptive investigation, and found that 36% of the cancer patients surveyed have used some form of CAM (range among countries: 15–73%). [12]
They identified a heterogeneous group of 58 therapies being used by cancer patients. Recent studies conducted in Europe report that CAM use by children is less common than by adult patients, but appears to be increasing in some European countries. [9, 13, 14] Although there have been some recent efforts in singular European countries to investigate paediatric CAM usage and characterise the CAM user, an international comparative survey has not yet been done. [15–18] The aim of this survey was to present an overview about characteristics of CAM use in children in different European countries and to estimate the prevalence of CAM use by the population in general, and more specifically by children, in Europe despite the scarcity of peer-reviewed published surveys.
Methods
A narrative, non-systematic review was assembled by combining expert opinions with a thorough and balanced review of available evidence from the literature. [19] An unrestricted literature search using the keywords, 'alternative', 'complementary', 'integrative', 'prevalence' and 'paediatric' or 'children' was performed by internet search using PubMed and open accessible search engines. All European countries with a minimum of 5 million habitants were initially included for which any data about CAM use in children were published in the last 10 years (29 countries), then expanded to include 2 smaller countries. Corresponding authors from these publications were contacted in each country, and they were asked to provide information about paediatric CAM use in their countries. These authors stand out because of their activities in investigating CAM in paediatrics and were of different professions and positions, such as physicians, scientist and others.
No negative selection had to be made, because paediatric CAM experts in European countries are very rare. We developed a semi-structured questionnaire divided into three sections for provision of(1) general information about CAM use,
(2) CAM use by paediatric patients, and
(3) space for an expert’s summary, conclusion, and personal comments.We requested that each participating expert also conduct a literature search in local and national databases using the keywords listed above translated into their native language. We asked the participating experts to extrapolate the prevalence of CAM use by both children and the population in general in their countries, estimate changes in prevalence over time and estimate CAM awareness of healthcare professionals and politicians in their countries based on published investigations. If published surveys were insufficient, we asked experts to complement existing data with their expertise.
Results
We obtained data from 20 (72%) of the 29 European countries to which we made requests, and data were provided by at least one expert in each of these 20 countries. Thus, expertise was available concerning CAM use from countries with altogether more than 534 million inhabitants (69% of the total European population) and covering an area of 5,590,000 km2 (43% of Europe). Some data about CAM use by the general population was available from surveys for 18 of the 20 (90%) countries, but usually only included adult respondents (Table 1)
Data from surveys published in international, peerreviewed journals were available for 12/20 (60%) countries, but these were of different quality, included different groups within the population, utilised different definitions for CAM use (1 per year, vs. 1 per lifetime, etc.) and/or inquired a restricted number of CAM therapies only (Fig. 1). This lack of a standardised approach and often also the examination of a study population non-representative for the entire country in published surveys prevented the calculation of general prevalence of CAM use in each country from published data alone. Participating local experts needed to extrapolate the general prevalence of CAM use in their countries from data provided in the surveys together with their own experience and using their own definitions of what to include as CAM therapies. We defined CAM use as using at least one type of CAM (defined by the country expert) at least once within the last year. The mean prevalence of CAM use by the general population across all 20 countries was estimated by the local experts to be 48% (range: 10–90%, Fig. 2). The mean prevalence of CAM use in Europe adjusted for the size of the population of each country was 56%.
Fourteen (70%) experts reported that CAM use was rising in their countries, and 11 (55%) experts reported that awareness about CAM in healthcare and politics was increasing (Fig. 3). Data were available for CAM use in children from surveys conducted in 11 (55%) countries, 9 (45%) of which were published in international, peer-reviewed journals. The mean prevalence of CAM use by children across all 20 countries was estimated by the local experts to be 45% (range: 5–90%). The mean prevalence in Europe adjusted for the size of the population of each country was 52%. A qualitative analysis of the most popular CAM therapies in Europe identified homeopathy, herbal medicine and acupuncture, but a wide diversity of CAM therapies were used by both children and adults in the surveyed countries. Some CAM types were not surveyed in some countries because no standardised list of CAM therapies exists. Details compiled from the information submitted by participating experts about CAM use are described for each country (in alphabetical order) in the following sections.
Austria (population 8.2 million)
Acupuncture, osteopathy, homeopathy, neural therapy, F.X. Mayr therapy, traditional Chinese medicine (TCM), orthomolecular therapy, anthroposophic medicine, applied kinesiology, and herbal medicine are CAM methods that are recognised by the Austrian Medical Board and for which standardised national training and qualification standards exist. In Austria, 11% of physicians are certified by the Austrian Medical Board for acupuncture, 6.6% for osteopathy, 2% for homeopathy, less than 1% for the remaining recognised CAM therapies.Children: There are no published data about the use of CAM by paediatric patients to date, however, the 'CAMbrella Austria' research consortium is currently gathering these data for publication. [20]
Comment: Only 6 paediatric departments in Austrian hospitals offer CAM via outpatient clinics. Very little paediatric CAM research has been conducted compared to the many and increasing number of CAM research groups for adults. We estimate that 60% of paediatric patients use CAM provided in private practices.Bulgaria (population 7.7 million)
Bulgaria possesses a long-standing tradition in herbal medicines. CAM was officially recognised in Bulgaria for the first time with the changes to the health law 2001. [21] The Bulgarian traditional medicine is grounded in phytopharmacy. [22] The use of many Chinese and Indian medical techniques, such as acupuncture and yoga, started after the turn to a market-oriented economy. Homeopathy has been used since 1990. [23] More recently Bulgarian authors have started analysing the wide-spread utilisation of dietary food supplements against minor ailments. [24–26]Children: No published data about CAM use by children are available.
Comment: Available studies show that interest in and usage of CAM in Bulgaria is increasing. Studies have focussed on safety evaluation of the widely used non-traditional herbs, such as Ginkgo, and created a methodological approach for establishing a national herbal drugs policy. [27]Cyprus (population 1.0 million)
Popular CAM therapies in Cyprus include homeopathy, herbal medicine, chiropractic, acupuncture, aromatherapy and reflexology. There are ten medical doctors practicing homeopathy on the island. One unpublished study was conducted by the Cyprus University in 2010. From the 600 interviews conducted in all districts of Cyprus (urban and rural), they found that 60% of the respondents had heard of homeopathy, 17% had visited a doctor practicing homeopathy, and 20% had used homeopathic medicine. Additionally, 75% of the respondents stated that homeopathy should be included in the National Health System.Children: No published data of CAM use by children are available.
Comment: CAM use is not popular among Cypriot patients, and no legislation exists for CAM. A few CAM practitioners are interested in training others, and there is no research currently being conducted in this field in Cyprus.Czech Republic (population 10.2 million)
No formal studies have explored CAM use in the Czech Republic. However, interest in CAM appears to be growing among the population. The number of CAM products available is increasing, as are seminars and courses about CAM. The number of healthcare professionals with CAM training is also growing. CAM therapies broadly ranging from homeopathy, anthroposophic medicine, TCM and Ayurveda to dietary methods, naturopathy, manipulative methods and spiritistic medicine are available in the Czech Republic.Children: No published data of CAM use by children are available.
Comment: Up to the recent past, CAM was not taken seriously by the public health authorities or ignored completely. A change from this position is taking place very slowly and is uncoordinated.Denmark (population 5.3 million)
In 2005, 42% of the Danish population reported that they had used CAM. Acupuncture (5%), reflexology (6%), and other types of bodywork (13%) were the most popular methods. [28] Half of all general practitioners offer CAM in their practices. [28] The typical Danish CAM user is either a child or a female between 25 and 64 years of age, often well-educated and living in a big city. [28, 29]Children: A study conducted in 2003 by the Odense University Hospital found that 53% of paediatric patients used CAM and that 23% had used it during the last month. [29] The types of CAM used were divided between herbal medicine (herbal drugs or dietary supplements, used by 15%), alternative therapies (i.e. acupuncture, used by 7%) and chiropractic (used by 2%). A positive effect of CAM treatment was experienced by 56% of patients using herbal drugs or dietary supplements, 79% using alternative therapies, and 92% using chiropractic, and 6% of patients reported experiencing side effects that appeared to come from the herbal treatment or change in diet.
Comment: CAM use has increased over the last 20 years, and most Danish patients now seem to prefer CAM treatments over treatment with pharmaceutical drugs. CAM is often used to treat children in Denmark, and its use in paediatrics continues to increase rapidly.France (population 60.8 million)
We estimate that fewer than 5 hospitals offer CAM treatments experimentally. Homeopathy and auriculotherapy are most popular. Only one survey has been published to date, and was performed in 2005 at 3 hospitals (both public and private) treating both adult and paediatric cancer patients including the Centre du Lutte Contre le Cancer Paul Strauss (CLCC), in Strasbourg. [30] Of the cancer patients surveyed, 28% used at least one CAM treatment. Homeopathy (60%), special diets or dietary supplements (44%), herbal medicine (37.5%) and mistletoe preparations (40%) were reportedly used.Children: There is no survey of CAM use in general paediatrics. Ten children with cancer were included in the summarised survey. Half of them reported using CAM: homeopathy (4 patients), mistletoe preparation (1), vitamin C (5), selenium (2) and fish oil (2).
Comment: CAM is most often suggested by general practitioners with a subspecialty in homeopathy and sometimes by CAM therapists or discovered by patients in the Internet. There is no recognition of CAM by the French government.Germany (population 82.5 million)
Approximately 70% of German people declared they use some form of CAM. [31] Popular CAM therapies are homeopathy, chiropractic, herbal medicine, TCM and anthroposophic medicine. About 30% (60,000) of German physicians have at least one CAM certification, and these are most commonly in homeopathy, naturopathy, acupuncture, chiropractic or anthroposophic medicine.Children: A study performed at an outpatient clinic for general paediatrics in 2005 revealed that 59% of the parents of children with chronic illnesses and 53% of the parents of children with acute illnesses gave their children some form of CAM. [32] Homeopathy, herbal and anthroposophic remedies were used most often. A study performed in patients with diabetes mellitus reported that 18% used CAM therapies that included homeopathy, vitamins and minerals and special diets, [33] and 35% of paediatric cancer patients reported using CAM (most frequently, homeopathy, nutritional supplements and anthroposophic medicine) in a survey conducted in 2004. [16]
Comment: CAM has a long tradition in Germany and is frequently used, but surveys of CAM use by paediatric patients have only recently been initiated. In general, professionals working in paediatrics in Germany are more open towards CAM therapies. The number of publications about CAM in specialist medical resources is increasing, as are the number of research publications and presentations at scientific meetings in the field of CAM.Greece (population 11.2 million)
A study published in 1996 indicates that 31% of the inhabitants of Attica (Athens’ district) had visited a CAM practitioner at least once. [34] This figure is estimated to be much higher now, based on sales of CAM medicines by pharmacies. According to a recently published study, Greek physicians display little interest in CAM, but are most familiar with homeopathy (59%), special diets (58%), antioxidants including vitamin C (56%) and acupuncture (48%). [35] Homeopathy, acupuncture, herbal medicine, reflexology and aromatherapy are most popular in Greece.Children: No published data for CAM use by children are available. Only 7 paediatricians are known to practice homeopathy throughout Greece.
Comment: The perceived proportion of patients using CAM is low. CAM is not officially recognised in Greece, although manufacture and circulation of CAM medicines are officially regulated by Greek legislation. Insurers cover homeopathy and acupuncture treatments from physicians only. Interest of Greek patients in CAM increases yearly, but Greek physicians display little interest in CAM.Hungary (population 10.0 million)
Approximately 50–60% of Hungarian people use some form of CAM, [36] with homeopathy and herbal medicine being most popular. Although, allopathic physicians are the most common providers of CAM, non-allopathic physicians and non-medical practitioners may provide specific CAM treatments. [8]Children: Of paediatric cancer patients, 60% report using some kind of CAM. [37] Natural products, dietary supplements, herbal medicines and special diets are most common.
Comment: CAM use has been increasing in Hungary since the fall of the Iron Curtain in 1989. [38, 39]Italy (population 58.6 million)
A survey by the National Institute of Statistics in 2005 showed that 14% of the population had used CAM, [40] and that homeopathy, manual treatments, herbal medicine and acupuncture were most common.Children: The 2005 survey reported that 10% of children between 0 and 14 years of age had used CAM, and that 8% of these children used homeopathy, 2% used herbal medicine (2%) and <1% used manual treatments or acupuncture. Other CAM therapies were not surveyed. In a study conducted in 1999, 46% of respondents reported using CAM to treat health problems of their children, [41] including homeopathy (72%), herbal medicine (17%), acupuncture (5%), anthroposophic medicine (2%), chiropractic (2%), osteopathy (1%) and oriental medicine (1%).
Comment: The National Federation of the Orders of Physicians and Dentists drew up a document in 2002 identifying disciplines that are recognised as non-conventional medicine and can only be practiced by medical doctors. These include acupuncture, herbal medicine, homeopathy, homotoxicology, anthroposophic medicine, Ayurveda and TCM.Netherlands (population 16.3 million)
Between 9 and 10% of Dutch people visit a CAM practitioner at least once yearly. [42] Homeopathy, acupuncture, naturopathic medicine and paranormal healers are most popular.Children: A study published in 1998 reported that 31% of a group of Dutch paediatric cancer patients used CAM. [43] A survey conducted in 2006 reported that almost one third of patients visiting a general paediatrician had used CAM in the past year. [44] Most frequently used were homeopathy (48%), herbal medicine (45%), nutritional supplements (28%) and manual therapies (28%). A third study revealed that almost 40% of parents of paediatric gastroenterology patients were turning to CAM for their child. [17]
Comment: CAM is frequently used by Dutch paediatric patients, and a change in thinking regarding CAM has been observed during the last 5 years. Paediatricians are more open to CAM, but not very knowledgeable about it. [45] Recently, an incidental but fatal adverse reaction was reported in the Netherlands for a 3–month old baby receiving craniosacral therapy. This incident has heightened awareness about the risks of CAM and the necessity of giving evidence-based advice to parents. [46]Norway (population 4.5 million)
Studies of the prevalence of CAM use in Norway have focussed on visits to CAM practitioners. The latest study reported that 49% of Norwegians were treated by CAM practitioners during the previous 12 months. [47] Massage, acupuncture, homeopathy and reflexology were most commonly used. Norway has an indigenous population, the Sami, which have their own folk medicine.Children: No data is available specifically about the prevalence of CAM use in paediatrics in Norway, although some studies did include children. The proportion of children under 10 years of age that visited homeopaths increased from 10% in 1985 to 26% in 1998. [48] Another study reported an increase in the proportion of children under 16 years of age who visited homeopaths, compared to others CAM providers, increased from 25% in 1995 to 36% in 2004. [49]
Comment: The Norwegian government has actively supported CAM research, treatment and legislative regulation. Research funding was provided in the 1990ies, and a national research centre and national information centre established in 2000 and 2007, respectively. A law regulating CAM practitioners was passed in 2004, and a school for acupuncture was officially accredited in 2009.Poland (population 38.6 million)
Approximately 58% of Polish patients use some form of CAM, including 35–94% of cancer patients, [50, 51] 68–70% of sclerosis multiplex patients, [52–54] 38% of patients with cardiac problems51 and 47–50% of patients with discopathy. The most popular CAM therapies were reported to be herbal medicine and bioenergotherapy, which were used by 42–83% patients. [54] A survey of oncological wards reported that 42% of the physicians treated their patients with at least one CAM method. [55]Children: The only study referring to children was conducted on paediatric cancer patients, and reported that 43% used CAM. [56] The types of CAM included spiritualism (47% of CAM users), herbal medicine (42%), bioenergotherapy (37%) and special diets (2%).
Comment: CAM is frequently used by patients in Poland, but published data for CAM use is limited, especially for paediatric patients. Existing data suggest large numbers of self-medicating adult and paediatric patients.Portugal (population 10.5 million)
Two published articles mentioned that CAM use in Portugal has increased over the last few years. [57, 58] No data exist on the prevalence of CAM use in the general population. A qualitative study mentions that approximately 25% of people contacted that lived in urban areas and 75% that lived in rural areas stated they visit some type of CAM therapists, which included acupuncturists, chiropractors, several specific types of local healers and herbal medicine practitioners. [59] A wide variety of ethnopharmacological studies on primarily wild plants used as herbal remedies in some regions of Portugal have been conducted, [60–64] suggesting that herbal medicine constitutes a major component of traditional medicine.Children: No data are available for CAM use by children.
Comment: CAM is only practiced in private clinics. Very little CAM research has been conducted in Portugal other than ethno-pharmacological investigations of plants used in traditional medicine. The appearance of several private CAM clinics and a look at books available in public libraries suggest that popular interest in CAM is rising.Slovenia (population 2.0 million)
No studies have explored the prevalence of CAM use in the general population or any specific group in Slovenia.Children: Unpublished results of a survey among parents of paediatric cancer patients showed that between 60% and 80% used some form of CAM to treat their children. The range of methods was wide, and included dietary interventions, homeopathy, TCM, Ayurveda and other biological, manipulative and energetic methods.
Spain (population 43.3 million)
Published data indicate that 24% of the population have used some type of CAM. [65] Most popular were yoga, acupuncture and chiropractic. A larger percentage of patients with chronic illnesses reported using CAM: 37% of patients with hepatitis, [66] 26% of patients with intestinal inflammatory illnesses [67] and 48% of patients with fibromyalgia. [68]Children: No published data about CAM use by children are available.
Comment: CAM is offered by physicians and therapists without standardised certification.Sweden (population 9.0 million)
Use of CAM has increased over the past 20 years in Sweden. An investigation in 1987 showed that 22% of the population of Stockholm had experience with CAM use, [69] and a study in 2001 reported that 50% of people living in Stockholm had used CAM at least once. [70] The most common CAM therapies were massage, natural products, chiropractic, acupuncture and naprapathy. Zone therapy, homeopathy, healing, anthroposophic medicine, rosen therapy, kinesiology and crystal therapy are less common but also practiced in Sweden. [71]Children: Swedish law prohibits practicing CAM on children under 8 years of age, reducing the published data available for CAM use in paediatrics in Sweden. One article has been published concerning communication therapy via expressive art [72] and another concerning pain experience and management by non-pharmacological strategies, thermal regulation and distraction. [73]
Comment: As EU regulations for CAM become available, it is expected that Sweden will raise the ban against CAM and follow EU directives.Switzerland (population 7.5 million)
Approximately 57% of Swiss people declared they use some form of CAM. [74] Popular CAM therapies are homeopathy, herbal medicine, TCM and anthroposophic medicine. Acupuncture, anthroposophic medicine, homeopathy, TCM, neural therapy and herbal medicine were an integral part of primary care in Switzerland between 1999 and 2005, and will be reintegrated between 2012 and 2017 to gather more scientific evidence about its pros and cons. [75]Children: A study performed at an intensive care unit in 1997 revealed that 18% of the parents of critically ill paediatric patients used some form of CAM. [76] In a current survey performed at the emergency department of the same hospital, 58% of all respondents stated that their children were using or had used some form of CAM therapies, 25% during the presenting illness. [15] Homeopathy was the most frequently used form of CAM (77% of all CAM users), followed by herbal medicine (64%), anthroposophic medicine (24%), TCM (13%) and Ayurveda (5%). [77]
Comment: CAM has a long tradition in Switzerland and is frequently used, but surveys of CAM use by paediatric patients have only recently been initiated. These efforts report high numbers of self-medicating paediatric patients and an exclusion of the physician from the decision-making process. Furthermore, some adverse effects and intoxications have been reported with remedies from CAM. [78]Turkey (population 73.7 million)
Most published data about CAM users in Turkey concern cancer patients. [] The prevalence of CAM use among patients with cancer varied between 36% [81] and 87%. [87] Some studies are also available about CAM use by healthy people, and most of these concern herbal preparations. [88]Children: Frequency of CAM use ranged from 46% to 77% for children. [89–94] Ozturk and Karayagiz concluded in 2008 that a majority of parents (57%) used CAM therapies for their children, with herbal therapy being most popular (77%). [18] Hizel-Bulbul et al. reported in 2008 that 27% of parents, who used natural/ herbal products for their children within 1 year, used them without a doctor’s recommendation. Commonly known alternative treatment methods were thermal water (83%), herbal tea (21%), acupuncture (15%), massage (6%), and bioenergy (2%). [92] A study performed in endocrinology centres for diabetes management in 2006 revealed that 52% of the parents of diabetic paediatric patients applied some form of CAM. [91] Herbal medicine (60% of all CAM users) was most popular. Most (69%) families did not report their CAM use to any healthcare professional. Three studies on CAM usage by paediatric oncology patients have been conducted in Turkey. The incidence of CAM usage for children with cancer varied between 49 and 77%, and herbal products were most commonly used. [79, 93, 94]
Comment: Despite the high prevalence of CAM use in Turkey, a gap exists between CAM users and healthcare professionals. Healthcare professions neither ask about CAM use nor inform their patients about CAM therapies, and also patients or their parents do not inform their physicians about CAM use during conventional treatment.UK (population 61.7 million)
CAM usage has increased in both adult and paediatric populations in the last decade. A 2010 survey of both adults and children documented that 60% had used CAM at least once in their lives and 35% had done so in the last year, [95] compared with surveys in 2000 and 2001 reporting CAM usage by adults to be between 20 and 28%. [96, 97]Children: In an systematic review of 2,781 children in the UK covering the years 1975–2005, CAM use ranged between 6 and 91%. [98] A UK-based cross-sectional survey from 2001 reported that 18% of children used some form of CAM at least once. [99] In 2008, a cross-sectional survey of all paediatric outpatients over a 3-month period at a major paediatric hospital reported that 37% of their patients used CAM. [100] CAM use was not reported to the responsible clinician in over half the cases. In two other cross-sectional surveys of 339 and 337 parents of paediatric patients, 54% and 51% had not told their paediatrician or GP about their CAM usage, respectively. [101] A large Scottish study of 161 general practices treating 167,865 children reported that 5% of practices provided homeopathy and herbal remedies, with most prescribed being for the treatment of infant colic (85%), musculoskeletal bruises (52%) and teething (49%). [102] Adverse effects either as a direct result of homeopathy or herbal remedies, or as a result of interactions between CAM and conventional medicines have been reported. [103, 104]
Comment: Healthcare professionals who do not supply CAM in their own clinics often refer or offer advice to patients about CAM. [105] Many healthcare professionals consider themselves not well informed enough about CAM to recommend it to their patients, but would like to see CAM more commonly included in NHS services. [102, 105–110] Parents in the UK commonly choose CAM therapies for their children, and 61% stated they are satisfied with the result, with 65% stating they would recommend it to others. [101] These trends appear to be driving diversification of the types of CAM therapies offered to and used by paediatric patients in the UK today.
Discussion
Little is known about CAM use by children. This is especially true for Europe, since the bulk of the literature is derived from children living in the USA. Comprehensive European analyses of CAM use in paediatrics are scare, which may partly be due to the diversity of languages, alphabets, religions, biodiversity and the historical background of Europe. Here we present a pan-European review about CAM in paediatrics, realised by combining data published in international journals, data from local or national surveys in original language conveyed by local experts, and expert perspectives about CAM availability, quality, use and popularity in their countries. Thus, a control mechanism was integrated by expert experience that increased the amount and quality of information about CAM use in Europe to provide the best comparative picture possible.
Published studies were of different quality and based on various definitions of CAM or CAM use. For instance, some studies asked only about specific therapies, some included all types of CAM and surveys qualified CAM use either as in a certain period of time or over the entire lifetime. In fact, the absence of a uniform definition of CAM for European countries also creates different country-based perspectives about what is included when all types of CAM are surveyed. Surveys about the use of CAM in European countries published in international, peer-reviewed journals were rare and did not contain data from a representative group of the population, preventing accurate extrapolation of mean CAM use in Europe. Although surveys of some kind had been conducted in 90% of 20 European countries included in our review, only 60% of these were published in peer-reviewed journals. All of these points of variability prevent the unified questioning in different countries that is required as the base for a systematic review. Our approach extended the data that could be included to those also published in the national language and attempted to bridge the lack of unified questioning with expert perspectives.
CAM therapies appear to be popular not only with adults, but also for children, in Europe. This was demonstrated both in the available surveys and in the opinions of the participating local CAM experts from the 20 larger European countries in our review. Our review incorporated data that can be extrapolated to represent 68% of European population, making it the most comprehensive effort to date. Our results suggest that more than 430 million citizens in Europe may use CAM, and that CAM use has a similar prevalence among European children. This widespread use of CAM and the anecdotal reports of adverse side effects either directly from CAM therapies, as a result of interactions between CAM and conventional therapies used in combination or because of insufficient training by healthcare providers strongly support a need for more structured CAM research. Investigations of how CAM treatments are conducted are needed to raise the quality of CAM treatment, and in cases where CAM is used in combination with conventional treatment, would also optimise the combined success of treatment.
Our use of local expert perspectives in this review to compensate for deficiencies in published surveys may have resulted in an overestimation of CAM use because of personal experiences and preferences of these experts. Despite its potential limitations, this survey can serve as a base for further efforts to investigate European CAM use in children. Several local experts described an increased awareness about CAM in healthcare and politics in combination with some type of wait-and-see strategy of their country regarding the regulation or training for CAM treatment. However, it appears that most countries will wait and adapt regulations for CAM use and training decided by the EU.
This is especially important for Sweden, where it is currently prohibited by law to treat children less than 8 years of age with CAM therapies. Evidence-based research necessary for pan-European harmonisation of paediatric CAM use and training are currently limited by lack of Europe wide funding and consortia for cooperative investigations in several European countries. The CAMbrella project has been initiated to assess CAM use in the general population. [20] A collaborative effort similar to CAMbrella is necessary for paediatrics to generate the evidence-based data necessary to inform EU legislation for CAM use and training specifically for children. The European Paediatric CAM Initiative was launched 2010 with paediatric CAM specialists from four European countries and is in the process of recruiting more. [111] This initiative may have the power to provide the basis for such a consortium to investigate CAM use in paediatrics.
Our survey implies further steps to reach the next pan- European goals for CAM use in paediatrics. Establishment of a European definition for CAM and CAM use would allow initiation of pan-European systematic reviews. Creating this definition requires standardisation of CAM use, designation of specific therapies as CAM and definition of a homogeneous study population. A validated unifying questionnaire should also be created that is adapted for specific European characteristics. These efforts would lay the groundwork to support extensive systematic investigations in European countries on CAM use in paediatrics.
Conflict of interest statement
The author has no conflicts of interest.
Acknowledgements
We thank K. Astrahantseff for helpful discussions about the paper and editing, and S. Freund for preparation of the figures.
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