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In the March European Journal of Pediatrics, researchers from the Netherlands published a review of adverse events associated with so-called complementary and alternative medicine (CAM) culled from three years of data from the Dutch Pediatric Surveillance System.

In the study, authors Bjorn Vos, Jan Peter Rake, and Arine Vlieger rely on the standard WHO definition of CAM:

a broad set of healthcare practices that are not part of that country’s own tradition or conventional medicine and are not fully integrated into the dominant healthcare system

I don’t particularly care for this definition, which isn’t surprising given the track record of the WHO when it comes to this sort of medical pseudoscience. The WHO distinguishes CAM from traditional medicine as well as “conventional medicine”, which we here at SBM would obviously prefer to call science-based medicine. Traditional medicine, such as Ayuverda and traditional Chinese medicine, is no different than CAM where it counts, which is the degree to which it has been studied and shown to work and to which a proper assessment of risk and benefit has been applied and respected.

According to the authors, pediatric CAM use is common in the Netherlands. They point out that 5% of kids under the age of 12 years, and 2% between 12 and 18 years, were seen by a practitioner of some flavor of CAM in 2017. This is roughly equivalent to the United States, with the bulk of visits here involving chiropractors. The best data from the United States is from 2012 though, so things may have changed. But if I had to guess, more kids were likely being exposed to chiropractic care in 2019 than in 2012. The pandemic almost certainly resulted in a drop in those visits, however.

The authors were unable to provide much data on home use of alternative medicine, but at least 12% of kids going to pediatricians were found to be taking a supplement or herbal remedy. It’s easy to imagine that overall use of alternative medicine in general is higher than that, particularly for children with chronic illnesses and cancer. That is definitely true in the United States. Fear and perceptions of vulnerability can be powerful motivators to explore so-called “other ways of knowing” when it comes to healthcare.

As I mentioned earlier, this study was based on data from the Dutch Pediatric Surveillance System or DPSS. This a surveillance system in place to keep tabs on a variety of “diseases, disorders, or incidents” by surveying more than a thousand pediatricians every month. The authors used DPSS data from January 2015 through December 2017 for this study, specifically looking for adverse events involving CAM use in children under the age of 19 years.

The authors specifically looked for CAM practices like chiropractic and massage therapy, as well as natural health products. These could include herbs, supplements, and vitamins and minerals not being prescribed to treat clinically relevant deficiencies. Pediatricians responding to the DPSS surveys were asked to assess the likelihood that an adverse event was caused by the CAM modality, and in cases where it was unclear they were contacted by the study authors. Adverse events were categorized as either indirectly, directly, or potentially caused by CAM, and further described as mild, moderate, severe, life-threatening, or fatal.

A total of 31 cases of adverse events related to CAM use were found during the 3 years of collected data and involved children from 10 weeks to 16 years of age. Two thirds of the cases (22) were described as indirectly harming a child by a delay or discontinuation of appropriate medical care (16), an extremely restrictive diet (4), or an incorrect diagnosis by a CAM provider (2). Of the nine cases of direct harm, three involved infants.

Of the 31 cases of adverse events, eight were documented as causing mild harm, twelve were associated with moderate harm, eight were severe, and three were life-threatening. Five of the children were admitted to a hospital, with one requiring intensive care for a month. More than half (18) of the cases were felt to have a certain causal relationship with CAM use, two were described as probable, nine as possible, and in two cases the likelihood of causation was determined to be “unassessable”.

While a variety of CAM modalities were documented in the DPSS data, the most common to be associated with adverse events were dietary supplements/vitamins, orthomolecular therapy, homeopathy, and naturopathy. Cases of direct harm were linked to supplements/vitamins, manual therapies, and herbal remedies. In eight of the cases, the CAM modality was provided by a physician.

Here are a few of the documented cases of severe and life-threatening harm:

  1. A 15-year-old diagnosed with sensitivity to electromagnetic radiation and being treated with bioresonance therapy was imprisoned in his home and socially isolated.
  2. An 8-year-old with autoimmune hypothyroidism had his prescribed mediation replaced with an herbal remedy.
  3. A 14-year-old with appendicitis developed septic shock with multiple organ failure after a delay in adequate treatment and despite homeopathy.
  4. A 14-year-old had a flare of his ulcerative colitis requiring colectomy after having his prescribed medication stopped by a naturopathic provider.
  5. A 5-year-old developed secondary adrenal insufficiency after his eczema was treated with herbs and a Chinese herbal ointment that contained large amounts of a corticosteroid.

What does it all mean?

This was the first study of its kind in the Netherlands, but it is consistent with similar data collected in numerous other countries. As expected, quackery is potentially very dangerous. The total number of adverse events may have been small, but when looked at through the prism of a rational assessment of risk versus benefits it is clear that unscientific approaches to health should be avoided. In particular, it appears that the biggest risk comes from discontinuing treatments prescribed by legitimate medical professionals and delaying appropriate evaluation.

In their discussion of the study results, the authors point out, and I fully agree, that this data is almost certainly limited by massive underreporting. Most adverse events are going to be mild and not make it to the attention of a child’s pediatrician. And caregivers often don’t report CAM use so a link to an adverse event might not be recognized.

They also discuss what is at the heart of why seeking care from a believer in alternative medicine is potentially harmful, although they put it a lot more nicely than I would have. Essentially, people who promote and practice quackery don’t have a clue what they are doing and are often incapable of recognizing real pediatric illness or the risks associated with changing or stopping a child’s treatment regimen. They don’t know what they don’t know and that makes them extremely dangerous.

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Posted by Clay Jones

Clay Jones, M.D. is a pediatrician and a regular contributor to the Science-Based Medicine blog. He primarily cares for healthy newborns and hospitalized children, and devotes his full time to educating pediatric residents and medical students. Dr. Jones first became aware of and interested in the incursion of pseudoscience into his chosen profession while completing his pediatric residency at Vanderbilt Children’s Hospital a decade ago. He has since focused his efforts on teaching the application of critical thinking and scientific skepticism to the practice of pediatric medicine. Dr. Jones has no conflicts of interest to disclose and no ties to the pharmaceutical industry. He can be found on Twitter as @SBMPediatrics and is the co-host of The Prism Podcast with fellow SBM contributor Grant Ritchey. The comments expressed by Dr. Jones are his own and do not represent the views or opinions of Newton-Wellesley Hospital or its administration.