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Use of Herbal Tea/Herbal Preparations for Children with Symptoms of Viral Upper Respiratory Infections

INTRODUCTION: Respiratory tract infections are common in children. To treat the symptoms of simple health problems, individuals look for natural healing methods that they can be easily prepared at home. The aim of this study is to determine the plants and herbal products used by the parents of children suffering from viral upper respiratory tract symptoms by using questionair. In the study, applications and products, other than plants used by families for their children were also investigated. METHODS: This study is a cross-sectional survey conducted at Gazi University Faculty of Medicine. A questionnaire form was used by scanning the existing literature and reviewed with the patients face to face by the researchers. The data obtained from the study were analyzed with the Statistical Package for the Social Sciences (SPSS) statistical program. RESULTS: About half of the participants reported that they used nonchemical drug practices for their children with upper respiratory tract infections. The most common practice was to prepare herbal tea (30,5 %), followed by mandarin/orange and/or their juice (26,9%) for oral application. The most used herbal tea for upper respiratory tract infections was made out of linden (Tilia sp.). Individuals who use linden usually prepared it as tea in other words by infusion and served their children 1-2 cups/1-3 times a week. Except for herbal tea, the participants mostly used honey (19.0%) for their children's symptoms. DISCUSSION AND CONCLUSION: Where available appropriate doses and dosage forms of herbal supplement products with scientifically proven efficacy and safety should be determined for the pediatric population. Parents should use these products based on recommendations of their pediatrician

Respiratory tract infections (RTIs) are one of the most common diseases in children. They mostly have viral origin and disturb the larynx, throat, trachea, mouth and nose. The most common symptoms are cough, fever, nasal congestion, runny nose and sore throat. 1 RTIs can be frustrating for both children and their parents, affecting daily activities as well as respiratory symptoms. 2 In order to treat the symptoms of simple health problems, individuals look for approaches that they can easily apply at home. 3 These methods, which are included in complementary and alternative medicine applications, are used in all age groups, including children. 4 Complementary and alternative medicinal practices, especially herbals, are frequently used for the management of symptoms of respiratory tract infections in children. 5,6 Studies in pediatric patients showed that herbal remedies are often used to treat coughs and colds. 7,8 Although there are many plants used for RTI symptoms, studies on the safe use of these plants in children are incomplete. There are ethical and moral limitations. Moreover, children have different physiology than adults and scientific data explaining the effectiveness of herbal products, their interaction with drugs and their side effects are lacking for all age groups. 9,10 The aim of this study is to determine those plant drugs and herbal products used by the families of children mostly suffering from viral upper respiratory tract symptoms. In the study, applications and products other than plants used by families for their children were also investigated. In this large-scale research, kinds of teas, preparation techniques of the teas, the herbs used in the teas, the preparation, the quantity and frequency of applications of those teas are examined.

MATERIALS AND METHODS
The research was conducted as a cross-sectional survey at the Department of Pediatric Infectious Disease in General Pediatrics at Faculty of Medicine, Gazi University in between July 1st 2020 and September 1st 2020. The approval was obtained for this study from the Ethics Committee at the Gazi University (12.05.2020-E.54135). All the participants voluntarily participated in the study. The research was conducted with the families of the patients, who applied to the hospital with the symptoms of viral upper RTI. The questionnaire was prepared based on the relevant literature and applied to the patients with face-to-face meetings. Cough, rhinorrhea, nasal congestion, sore throat and fever were determined as symptoms of upper RTI and their presence in children was questioned. In the first part of the questionnaire, the descriptive characteristics of the participants and their children were examined and a total of 250 individuals were included in the study. Since the amount of the salary can change in numbers in our country, respondents were asked to categorize their family income as ''very low'', ''low'', ''medium'', ''good'' or ''very good''. In the next sections, herbals and non-pharmacological applications used for upper respiratory tract symptoms are presented. In addition to questions with two options such as "Yes" and "No", 'Multiple response' questions where more than one option can be selected were also included. The preparation technique, frequency and amount of used herbal teas was also examined. Herbal tea preparation techniques were classified as infusion, decoction and maceration. Infusion is defined as brewing with boiling water, decoction is adding cold water and boiling with it, and maceration is adding water, keeping it at room temperature by shaking occasionally. The data obtained from the study were analyzed with the Statistical Package for the Social Sciences (SPSS) 26.0 statistical program. The frequency of participant responses is shown in the accompanying tables and figures. Cross tables were created to correlate the responses and chi-square tests were conducted. The level of significance for all the statistical analyzes were accepted as p<0.05.

Characteristics of participants and children
The characteristics of the participants and children are shown in detail in Table 1. A total of 250 individuals participated in this study, in which 72.0% were mothers, 25.2% were fathers and 2.8% were other individuals. The majority of the individuals (65,2%) between the ages of 30 and 44 and more than half of the participants (65,2%) reside in the city center, moreover, about 65% of respondents described their family income as 'middle'. As for education of the participants 29.6% of the participants are high school graduates, 29.2% are university graduates and 4.8% are postgraduate. The participated children were mostly between the ages of 3 and 6 (28.0%), 52% of the children were girls and 48% were boys, who generally did not have chronic illnesses or did not take regular medications. The most common upper respiratory tract symptoms in children were cough (25,8%) followed by rhinorrhea (20,5%).

Characteristics
Number (

Use of non-pharmaceutical products
Non-drug applications and products used are given in Table 2 and symbolized in Figure 1. The number of participants who apply or did not apply anything other than medication for their child's upper respiratory tract infection symptoms was close to. 47,2 % of the participants reported that they used non-drug therapeutic approaches for their children with upper respiratory tract infection symptoms. These applications were herbal tea, honey milk, vitamin supplements, mandarin/orange and/or their juice, and Vicks ® rub, steam application. The most common non-drug practice was to drink herbal tea (30,5 %). The rate of use of herbal and/or herbal products, which was asked as a different question, was 34 %. Participants reported that they mostly used honey (19,0 %) for their children's symptoms, apart from herbal tea as a product. Differently, among the frequently used products were grape molasses (11,4%), vitamins (6,9%), carob molasses (5,9%) and fish oil (5,2%).

Percentage (%)
Before applying to the hospital for your child, did you apply anything other than medication for upper respiratory tract infection symptoms? Yes

Use of herbal tea and products
The details about application of herbal teas and herbal products by the participants are given in Table 3 and Table 4. Participants (34 %) using herbal tea/product for their children's symptoms, used them most often at the onset of diseases (61,2 %). Herbal use declined after the disease progressed. The majority of the participants did not use prescribed medicine and herbal products together (89,6 %). Participants applied herbs mostly by brewing or boiling. The most used herbal hot drink was reported as linden infusion/decoction (44,2%) for upper respiratory tract infection symptoms, followed by mint-lemon (28,6%) infusion/decoction. Individuals, who use linden for their children reported that they usually prepared it by infusion and they made their children drink 1 to 2 cups, usually 1 to 3 times a week. On the other hand, they prepared mint-lemon by decoction and made them drank 1-2 cups. The other reported herbs were sage, cinnamonginger, winter tea, chamomile, quince, fennel, rosehip, marshmallow, green tea and pomegranate flower.
The data associated with herbal use and characteristic features of the children/participants are presented in Table 5. There was a statistically significant relationship between the age of the children and herbals use. Children, between the ages of 7 and 11 highly consumed herbal teas (p<0.05). On the other hand, herbal usage was low in children with chronic diseases and taking regular medication. Analysis showed that parents between 30 and 44 years old and mostly mothers used herbs/herbals for their children. Among those parents, there were university graduates, having a middle-income and living in the city center. However, the relationship between herbs usage and parents' gender, age, education, and income level was not statistically significant (p>0.05). Participants who used herbs for themselves were more probably to use herbs for their children. Individuals who did not use herbs for themselves generally did not use herbs for their children (40,8 %) either. The rate of the participants, who both themselves and their children used herbal medicine was 31.2%. Participants reported that they learned the use of herbals mostly from relatives, family elders, neighbors and friends (60,5 %). The number of participants who received advice from health professionals was quite low (15,5 %). For this reason, the rate of use of herbal products sold in pharmacies (Umca ® and Sambucol ® ) was also very little (1,5 %). Almost half of the individuals obtained the herbs from herbalists or spice shops. Apart from that, they mostly obtained from village/hometown and market/supermarkets. The number of individuals who bought the herbs from the pharmacy was quite low (5 %). Individuals using herbals preferred them because they thought they were useful and less harmful than chemicals. About half of the participants who did not use herbals reported that they considered them ineffective (49 %). Some of them described herbs as expensive (1,9 %) and harmful (13,5 %), additionally, 4.8% of the participants reported that their family doctor said they should not use herbal medicine because they are already taking medicine.

DISCUSSION
The use of herbs and herbal products in pediatric populations has been studied mostly under the heading of complementary and alternative medicine (CAM). Studies have focused more on determining for what kind of symptoms the CAM are used in general pediatric populations. In Italy, CAM is mostly used to treat ear, nose and throat pathologies. The most used methods were phytotherapy and homeopathy. 11 In southwest England, 50% of the children had used complementary medicine who suffered from upper respiratory tract infections. 12 As well as in the United States of America (USA), complementary and alternative medicine practices were also frequently used for respiratory diseases in children.
More than 50% of users have been using vitamin supplements and over 40% have been using herbal treatments. Aloe vera, chamomile tea, echinacea, garlic and ginger were among the most consumed herbs. 13 Among the studies investigating herbal use in specific pediatric populations, studies in children suffering from respiratory tract disorders are relatively few. In Australia, it has been reported that parents of children suffering from acute respiratory infections commonly use chest lotions/herbal liniments, lemon and honey mixed drinks, only honey and probiotics for treatments. On the other hand, herbals were used in children, less than these applications. Elderflower, echinacea, ginger, mint, turmeric and herbal combinations were among the herbals used. Parent's educational status played a role in the use of complementary and alternative medicine in children. 14 In Turkey, 77.2% of mothers who applied to the emergency department with respiratory system complaints in their children, reported that they applied complementary and alternative medicine to their children. The most common practice was the use of herbal products and the plants were as follows linden (50.9%), mint-lemon (40.8%) and carob (29.4%). 15 In another study, conducted to determine the approaches of mothers to their children having cough, it was determined that 72.8% of mothers benefited from herbals such as linden and mint. The same study indicated that practices such as eating tangerine/orange fruits, drinking milk with honey, applying vics on all over the body were applied for healing. 16 In Saudi children, the herbal medicine use rate for acute lower respiratory tract disease was 59.3%. Sesame oil, fenugreek, olive oil, and dates were also often used. 17 Analysis of the results showed that children's families used a variety of non-drug practices for their children with viral upper respiratory tract symptoms. It has been determined that the applications and products used by families for their children are easily accessible and applicable at home. The results obtained in this study are similar to the results of previous studies. 15,16 Previous studies have shown that female parents tends to use more CAM and herbs for their children; even, some studies were conducted with mothers only 11,15,16 . Similarly, in this study, herbs were mostly used by mother, moreover, similar to previous studies, participants who used herbs were mostly university graduates. 11,14 Although this suggested that the participants with higher education level researched herbs more, additionally, the participants reported that they learned the information mostly from their family members. Participants residing in the city center used herbs more. Considering that the participants mostly obtained herbs from herbalists, it may be due to easier access to herbalists in the city center.
The survey results showed that honey is the most used product of all the non-pharmacological therapeutic approaches. In addition to its use alone, honey has also been used as a mixture by adding it to plants. Previous studies have also shown that honey is often used for respiratory problems in children, especially for cough. Due to its antibacterial, antimicrobial and topical soothing properties, honey has been suggested as a potential treatment for coughs and colds. 18 A Cochrane review compared the effectiveness of honey for acute cough in children with the effectiveness of diphenhydramine, dextromethorphan, and salbutamol. Results showed that honey reduced the cough-time better than placebo and salbutamol. For cough symptoms, honey was approximately equally effective with dextromethorphan, while it was more effective than diphenhydramine, control and placebo. There was no difference between honey and others in terms of adverse effects. 19 On the other hand, honey is not recommended in children younger than 1 year old as it may cause infantile botulism. 20 Lindens were the most applied herbs for children's symptoms in our study. According to the European Medicines Agency (EMA), linden flowers can be used to relieve cold symptoms. 21 Commission E approved the use of linden for cough and bronchitis. According to the PDR, linden flowers can be used for colds of the respiratory tract due to their diaphoretic effect and for febrile colds and infectious diseases, where sweating treatment is required. 22 On the other hand, these indications stated in the monographs are based on traditional use and are not supported by clinical studies. The EMA recommends the preparation and use of tea from linden flowers as an infusion, while according to the PDR it can be prepared both as an infusion and a decoction. Although it is reported in the monographs that linden has no serious side effects, the EMA does not recommend the use of linden in children under 4 years of age due to insufficient data. In our study, it was determined that the participants prepared linden with both infusion and decoction methods, mostly infusion. Moreover, this study used linden in children under 4 years old, contrary to what is stated in the EMA. Individuals stated that they mostly used herbal teas or products for their children at the onset of illness. Herbal use were declined after the disease progressed. This shows that parents turn to herbs as a first and simple remedy when their child start showing symptoms. When the disease progresses, they prefer usin the drugs that their doctors prescribe. Generally, they do not prefer to use the prescribed drug and the herbs together. The age of the child and the use of herbs by the families themselves were effective in the use of herbs in children. Participants who used herbs generally used them because they thought they were beneficial, while those who did not use them generally thought they were ineffective.

STUDY LIMITATIONS
This study was planned and the permissions were obtained before the pandemic but carried out during the COVID19 pandemic condititons. Therefore, the number of the participants were limited to 250 due to the closures of the clinics time to time. Moreover, the variation of participants was mostly from the city, since not many parents made to the city hospital due to the pandemics. Since the study was conducted during the first 6 months of the pandemic, parents' habits might be same as before pandemics through their children.

CONCLUSION
This study is valuable for public health and clinicians in terms of presenting the data on herbal use applied for children in detail in the univeristy hospital. Most of the parents unconsciously used CAM for their children with the information they learned from relatives, family elders, neighbors and friends. They did not have enough information about the preparation technique of the herbs, the frequency, duration and amount of use. As a conclusion, appropriate doses and dosage forms of herbal supplement products with scientifically proven efficacy and safety