Dietary Supplement Use in Children: Concerns of
Efficacy and Safety
American Family Physician - Volume 71, Issue 6 (March 2005) - Copyright 2005
American Academy of Family Physicians - About This Journal
Editorials
Dietary Supplement Use in Children: Concerns of Efficacy and Safety
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. This increase is mirrored in children: more than 50 percent of all
[1]
young children and more than 30 percent of all adolescents in the United States have
used a dietary supplement. Family physicians must be prepared to answer difficult
[2]
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. Other dietary supplements commonly used by children are
[2]
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, 41 percent of 520 adolescents reported that they had used herbal or green tea,
[3]
zinc, echinacea or echinacea/goldenseal, ginseng, ginger, ginkgo biloba, soy
supplements, omega 3 fatty acids or fish oil, creatine, weight loss supplements, St.
Johns 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. Johns wort. [4] [5] [6] [7]
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.micromedes.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 http://familydoctor.org/364.xml
medicine
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. A recent study of Ayurvedic herbal products found
[8] [9]
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. Only 45 percent of parents who give their
[10]
children herbal products reported discussing these products with their childs primary
health care professional. Parents learn about supplements from family, popular press,
[10]
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 guidelines may be
[8]
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.
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.
Address correspondence to Paula Gardiner, M.D., Landmark Center, 401 Park Dr.,
Suite 22A-West, Boston, MA 02215 (e-mail: [email protected]).
Reprints are not available from the author.
GARDINER M.D. 1 2
1
Harvard Medical SchoolBoston, Massachusetts
2
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.
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