Editorials

Dietary Supplement Use in Children: Concerns of Efficacy and Safety

Am Fam Physician. 2005 Mar 15;71(6):1068-1071.

Increasing numbers of patients in the United States are using herbal therapies and dietary supplements; between 1990 and 1997, there was a fivefold increase in the use of herbal therapies.1 This increase is mirrored in children: more than 50 percent of all young children and more than 30 percent of all adolescents in the United States have used a dietary supplement.2 Family physicians must be prepared to answer difficult questions about the use of herbal dietary supplements in children: Do they work? Are they safe? Which products do you recommend?

The most commonly used supplements are multivitamins, minerals, vitamin C, iron, and ergogenic aids.2 Other dietary supplements commonly used by children are echinacea, peppermint, chamomile, probiotics, ginger, fish oil, and garlic. Adolescents have easy access to dietary supplements that claim to promote weight loss or enhance athletic achievement, school performance, or physical appearance. In a national online survey,3 41 percent of 520 adolescents reported that they had used herbal or green tea, zinc, echinacea or echinacea/goldenseal, ginseng, ginger, ginkgo biloba, soy supplements, omega 3 fatty acids or fish oil, creatine, weight loss supplements, St. John’s wort, valerian, ephedra, or feverfew. Children with chronic conditions such as cystic fibrosis, attention deficit disorder, asthma, atopic dermatitis, allergic rhinitis, cancer, inflammatory bowel disease, and rheumatoid arthritis have higher dietary supplement use than children without these conditions. In children with chronic conditions, the most commonly used dietary supplements were Chinese herbal medicine, ginkgo biloba, echinacea, and St. John’s wort.47

Compared with pharmaceuticals, few studies are available on the clinical effectiveness and safety of herbal and dietary supplements in children, adolescents, infants, and pregnant women. Some risks are unique to children who use dietary supplements: incorrect dosing (based on age and weight of the child), side effects, drug-dietary supplement interactions, and severe allergic reactions. Although the literature is scant, several evidence-based resources can be used at the point of care to help with clinical decision-making (Table 1). Additionally, the American Academy of Family Physicians and the American Academy of Pediatrics have made recommendations on the use of dietary supplements (Table 2).

TABLE 1

Evidence-Based Internet Resources for Herbal and Dietary Supplements

Altmedex

Subscription service through Micromedex

http://www.micromedex.com/products/healthcare

Holistic Kids

Pediatric integrative medicine education project

http://www.holistickids.org

Longwood Herbal Task Force

Free patient handouts and evidence-based monographs on common childhood herbs

http://www.mcphs.edu/herbal

MedWatch

Report adverse events and drug-herb interactions

http://www.fda.gov/medwatch

Telephone: 800-FDA-1088 (800-221-1088)

National Institutes of Health Office of Dietary Supplements

Free patient handouts available

http://ods.od.nih.gov

Natural Medicines Comprehensive Database

Subscription service with evidence-based monographs

http://www.naturaldatabase.com

Natural Standard

Subscription service with evidence-based monographs

http://www.naturalstandard.com/

TABLE 1   Evidence-Based Internet Resources for Herbal and Dietary Supplements

View Table

TABLE 1

Evidence-Based Internet Resources for Herbal and Dietary Supplements

Altmedex

Subscription service through Micromedex

http://www.micromedex.com/products/healthcare

Holistic Kids

Pediatric integrative medicine education project

http://www.holistickids.org

Longwood Herbal Task Force

Free patient handouts and evidence-based monographs on common childhood herbs

http://www.mcphs.edu/herbal

MedWatch

Report adverse events and drug-herb interactions

http://www.fda.gov/medwatch

Telephone: 800-FDA-1088 (800-221-1088)

National Institutes of Health Office of Dietary Supplements

Free patient handouts available

http://ods.od.nih.gov

Natural Medicines Comprehensive Database

Subscription service with evidence-based monographs

http://www.naturaldatabase.com

Natural Standard

Subscription service with evidence-based monographs

http://www.naturalstandard.com/

TABLE 2

Guidelines on CAM and Dietary Supplements

Guideline Web site

Calcium

http://www.aap.org/policy/re9904.html

CAM

http://www.aafp.org/x6681.xml

Echinacea

http://familydoctor.org/744.xml

Ephedra

http://www.aafp.org/x20491.xml

Folic acid

http://www.aap.org/policy/re9834.html

Herbal medicine

http://familydoctor.org/364.xml

Vitamin D

http://www.aap.org/policy/s010116.html


CAM = complementary and alternative medicine.

TABLE 2   Guidelines on CAM and Dietary Supplements

View Table

TABLE 2

Guidelines on CAM and Dietary Supplements

Guideline Web site

Calcium

http://www.aap.org/policy/re9904.html

CAM

http://www.aafp.org/x6681.xml

Echinacea

http://familydoctor.org/744.xml

Ephedra

http://www.aafp.org/x20491.xml

Folic acid

http://www.aap.org/policy/re9834.html

Herbal medicine

http://familydoctor.org/364.xml

Vitamin D

http://www.aap.org/policy/s010116.html


CAM = complementary and alternative medicine.

Even if a supplement has proven clinical efficacy and safety, the quality of supplements and lack of standardization are obstacles in making recommendations. Mislabeling; misidentification; contamination with heavy metals, pesticides, or herbicides; and adulteration with other herbs or pharmaceuticals could cause toxicity in a child, but not in an adult.8 A recent study9 of Ayurvedic herbal products found that 20 percent were contaminated with heavy metals (e.g., lead, arsenic, mercury); 50 percent of the contaminated products were marketed for children.

Parents give their children dietary supplements for many reasons (e.g., health maintenance, prevention and treatment of acute and chronic diseases), yet parents do not always report the use of these supplements to their family physicians. Of 142 families surveyed while waiting in an emergency department, 45 percent reported giving their child an herbal product.10 Only 45 percent of parents who give their children herbal products reported discussing these products with their child’s primary health care professional.10 Parents learn about supplements from family, popular press, television advertisements, health food stores, and the Internet. It is critical for physicians to know what dietary supplements their patients are using and why, and to clearly document the use of these supplements. The following guidelines8 may be helpful when talking with parents about using dietary supplements:

• Ask all parents which herbal or dietary supplements (e.g., traditional remedies, teas, multivitamins, special foods, over-the-counter products) they are giving their children.

• Encourage parents to seek professional guidance for information on efficacy and safety before using dietary supplements. Dietary supplements may have beneficial effects as well as expected and sometimes unexpected toxicity. Dietary supplements are not regulated as strictly as drugs by the U.S. Food and Drug Administration, so it is truly a case of “buyer beware.” Variable and unpredictable concentrations, ingredients, and contaminants are of concern, especially when such products are used in children.

The Author

PAULA GARDINER, M.D., is a research fellow in the Division for Research and Education in Complementary and Integrative Medical Therapies at Harvard Medical School, Boston, and director of integrative medicine at Tufts University Family Medicine Residency, Malden, Mass.

Address correspondence to Paula Gardiner, M.D., Landmark Center, 401 Park Dr., Suite 22A–West, Boston, MA 02215 (e-mail: paula.gardiner@hms.harvard.edu). Reprints are not available from the author.

Dr. Gardiner is supported by an institutional national research service award for training in alternative medicine research (T32AT00051). The views expressed in this editorial are those of the author and do not represent the views of the National Center for Complementary and Alternative Medicine or the National Institutes of Health.

REFERENCES

1. Muller JL, Clauson KA. Pharmaceutical consideration of common herbal medicine. Am J Managed Care. 1997;3:1753–70.

2. Kleinman R. Current approaches to standards of care for children: how does the pediatric community currently approach this issue? Nutr Today. 2002;37:177–9.

3. Wilson K. Herbal medicine use by adolescents in the US: preliminary data and feasibility of online survey methods. In: Abstracts of the Annual Meeting of the Society for Adolescent Medicine. March 2003. J Adolesc Health. 2003;32:127.

4. Johnston GA, Bilbao RM, Graham-Brown RA. The use of complementary medicine in children with atopic dermatitis in secondary care in Leicester. Br J Dermatol. 2003;149:566–71.

5. Cala S, Crimson ML, Baumgartner J. A survey of herbal use in children with attention-deficit-hyperactivity disorder or depression. Pharmacotherapy. 2003;23:222–30.

6. Heuschkel R, Afzal N, Wuerth A, Zurakowski D, Leichtner A, Kemper K, et al. Complementary medicine use in children and young adults with inflammatory bowel disease. Am J Gastroenterol. 2002;97:382–8.

7. Kemper K, Wornham WL. Consultations in holistic pediatric services for inpatients and outpatient oncology patients at a children’s hospital. Arch Pediatr Adolesc Med. 2001;155:449–54.

8. Woolf AD. Herbal remedies and children: do they work? Are they harmful?. Pediatrics. 2003;112:240–6.

9. Saper RB, Kales SN, Paquin J, Burns MJ, Eisenberg DM, Davis RB, et al. Heavy metal content of ayurvedic herbal medicine products. JAMA. 2004;292:2868–73.

10. Lanski SL, Greenwald M, Perkins A, Simon HK. Herbal therapy use in a pediatric emergency department population: expect the unexpected. Pediatrics. 2003;111:981–5.


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