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Complementary and Alternative Medicine in Pediatric Gastroenterology.

T o the Editor: In their recent survey on the use of complementary and alternative medicine (CAM) in children with inflammatory bowel disease, Serpico et al (1) demonstrated that CAM therapy was used by 84% of patients, although only a minority of patients/families considered themselves to be using CAM (approximately 24%). The 3 most common CAM therapies were vitamins/supplements, stress management techniques, and/or dietary changes. Important factors associated with using specific CAM therapies included self-reported adverse effects caused by conventional therapy (P< 0.01) and moderate/severe disease activity (P< 0.01). Given the controversy surrounding the (non-) effectiveness of CAM, we would like to add some further information on this important issue. In a systematic analysis, we analyzed all Cochrane reviews published between 1995 and 2012 with regard to CAM use in children (2). Main outcome variables were percentage of reviews that concluded that a certain intervention provides a benefit, percentage of reviews that concluded that a certain intervention should not be performed, and percentage of studies that concluded that the current level of evidence is inconclusive. A total of 135 reviews were included, most from the UK (29/135), Australia (24/135), and China (24/135). Only 5/135 (3.7 %) reviews suggested a recommendation in favor of a certain intervention; 26/135 (19.4 %) issued a conditional positive recommendation, and 9/135 (6.6 %) reviews concluded that certain interventions should not be performed. Ninety-five reviews (70.3 %) were inconclusive. The proportion of inconclusive reviews increased from the first to the second interval, and then remained roughly on the same high level during the third time interval (1995–2000, 15/27 [55.6 %]; 2001–2006, 33/44 [75 %]; and 2007–2012, 47/64 [73.4 %]). The 3 most common criticisms of the quality of the studies included were more research needed (82/135), low methodological quality (57/135), and small number of study participants (48/135). In parallel with the above stated analysis, we conducted a systematic literature review, including all Cochrane reviews published by the Cochrane Review Group in the field of pediatric gastroenterology between 1993 and 2012 (3). In total, 86 reviews in the field of pediatric gastroenterology were included. The majority of reviews assessed pharmacological interventions (46/86); other important fields included prevention (15/86) and nutrition (9/86). A total of 33/86 reviews issued definite recommendations (positive, 19/86; negative, 14/86). The remaining 53/86 reviews were either inconclusive (24/86) or only of limited conclusiveness (29/86). The percentage of inconclusive reviews increased from 9% (1998– 2002) to 19% (2003–2007; P< 0.05) to finally 24% (2008– 2012) (P< 0.05). The 3 most common reasons for the need for further research were heterogeneity of studies (26/86), small number of patients (18/86), and insufficient data (16/86). Given the disproportionate number of inconclusive reviews in the field of CAM use in pediatrics, also when compared with other subspecialties in pediatrics (4), there is an ongoing need for high-quality research to assess the potential role and limitations of CAM in children. Our data may help physicians, pharmacists, and other health care workers when discussing different aspects of CAM in an open manner with children, adolescents, and their parents, thereby being able to provide them with information regarding the (non-) effectiveness of various CAM therapies. Health care workers should be aware that many CAM substances are sold over the counter with the customer knowing little to nothing about potential intrinsic adverse effects and possible interactions with other medications (5). With respect to medicinal CAM such as homeopathic remedies, herbal drugs, nutritional supplements, and the like, pharmacists seem to be in a very important position, having both the knowledge and the duty to inform parents and patients adequately. In conclusion, and in line with the results and remarks from Serpico et al (1), pediatric gastrointestinal physicians should be knowledgeable of different aspects of CAM therapies and open to discuss these aspects with families/caregivers and patients.