Eur J Clin Pharmacol (2012) 68:16391645 DOI 10.

1007/s00228-012-1294-6

PHARMACOEPIDEMIOLOGY AND PRESCRIPTION

Complementary or alternative? Patterns of complementary and alternative medicine (CAM) use among Finnish children
Sanna M. Siponen & Riitta S. Ahonen & sa Kettis & Katri P. Hmeen-Anttila

Received: 9 February 2012 / Accepted: 13 April 2012 / Published online: 10 May 2012 # Springer-Verlag 2012

Abstract Purpose The aim of this study was to measure patterns of complementary and alternative medicine (CAM) use among Finnish children and to explore whether CAM use among children is mainly complementary or alternative. Methods We carried out a cross-sectional population-based survey in spring 2007. The study population consisted of a representative sample (n 0 6,000) of Finnish children under 12 years of age. A questionnaire was sent to their parents, and 4,032 questionnaires were returned (response rate 67 %). Pearsons chi-square test and logistic regression analysis were conducted to measure factors associated with CAM use. Results The prevalence of CAM use among children was 11 %. Fish oils and fatty acids (6 %) followed by probiotics (4 %) were the most commonly reported CAMs used. Being the first born, using vitamins and having at least one symptom predicted the use of CAMs. Parental use of vitamins and CAMs were also associated with CAM use among children. In the preceding 2 days, 3 % of children in the study had used only CAMs, and 7 % had used a CAM concomitantly with prescribed and/or over-the-counter medicines.
S. M. Siponen (*) : R. S. Ahonen School of Pharmacy/Social Pharmacy, University of Eastern Finland, P.O Box 1627, 70211 Kuopio, Finland e-mail: sanna.siponen@uef.fi . Kettis Department of Pharmacy, Uppsala University, Uppsala, Sweden K. P. Hmeen-Anttila Finnish Medicines Agency, Mannerheimintie 103b, Helsinki 00301, Finland

Conclusions Our results indicate that the use of CAMs among Finnish children is mainly for improving health and alleviating symptoms, especially in families where at least one parent also uses these modalities. CAMs were mainly used as complementary rather than as an alternative to conventional care. Healthcare professionals should be aware of this complementary use of CAMs and medicines in patients to avoid risks of potential interactions. Keywords Child . Population-based survey . Complementary and alternative medicine . Finland

Introduction Complementary and alternative medicines (CAMs) are usually defined as preparations and practices that are not regarded as a part of conventional medicine and which may be used to complement or as an alternative to conventional medicine [1]. The use of CAMs is common among adults, but has also been reported among children, especially among those with a parent who uses CAMs [27]. Parents often perceive CAMs as more natural and safer than conventional medicines. Parents fear of possible side-effects associated with conventional medicine use is one of the most commonly cited reasons for giving CAMs to their children [2, 3]. The prevalence of CAM use among children has been reported to vary between 9 and 57 %, depending on the definition of CAM used in the study and/or the length of the recall period [310]. Most such studies have focused on measuring the use of CAM among children in certain populations, such as among hospital patients [4, 5, 912] or children with a long-term disease, such as asthma [13, 14], cancer [15] or human immunodeficiency virus (HIV) [13].

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Far less is known about the patterns of CAM use among children in the general population [3, 6, 7, 16], especially in Europe [3, 16]. Several studies conducted in Western countries have shown that the use of prescription medicines among children predicts CAM use [6, 8, 10, 11]. However, to the best of our knowledge, research on the prevalence of CAM used in conjunction with conventional medicines among children is rare [1012, 17], especially in the general population. Obtaining information on CAM use in the general paediatric population is important because CAMs may interact with conventional medicines [17] and may also result in ineffective treatment if used instead of conventional medicines. The aim of this study was to explore the patterns of CAM use among a general population of Finnish children under 12 years of age and to determine whether the use of CAM among Finnish children is mainly complementary or alternative.

in accordance with the local and national ethical instructions for research (National Advisory Board on Ethics: http:// www.tenk.fi/ENG/function.htm). Main outcome measures The use of CAMs was measured by asking the parent to report the names of medicinal herbs, botanicals, or homeopathic remedies that the child had used in the preceding 2 days. The short recall period of 2 days was chosen in order to limit recall bias and to obtain comparable results with a previous population-based study in Finland [16]. The reported preparations were categorised as fish oils and fatty acids, probiotics, homeopathics and other CAMs (e.g. products for the common cold and stomach ailments). Alternative use was defined as use of only CAMs by children, whereas complementary use was defined as use together with prescription and/or OTC medicines. Background variables

Methods Definition of CAM In this study, CAM was defined as traditional herbal medicinal products, homeopathic and anthroposophic products, and food supplements (excluding vitamin supplements) that are not regarded as medicines in Finland. Thus, practices such as massage therapy, chiropractic and acupuncture were excluded. The legal and regulatory framework for the sale of CAM products in Finland has been described previously [18]. Data collection This survey was conducted in the spring (FebruaryApril) of 2007 as a postal survey by the School of Pharmacy, University of Eastern Finland. The study population consisted of a representative sample of 6,000 Finnish children under 12 years of age, randomly selected from the database of the Finnish National Population Register Centre. This database holds information on everyone living permanently in Finland. Children in institutional care were excluded. A six-page questionnaire was sent to parents, primarily to the mothers, addressed to the parent who usually takes care of the child's medication. Two reminders were sent. The questionnaire consisted of the following sections: background information on the child, the childs medicine use, medicine information sources, and background information on the parent. The childs name was printed on the questionnaire to indicate which child was included in the study sample. On return of the questionnaire, the name of the child was removed and replaced by a random number to ensure confidentiality. The study setting and research process were Background variables included the childs age, gender, birth order, self-rated health, as reported by the parent on a 5-item Likert scale, the number of diseases of the child diagnosed by a physician, as reported by the parent, the number of current symptoms of the child, reported by the parent on an 11-item symptom list, current prescribed medicine use, over-the-counter (OTC) medicine use and vitamin use in the preceding 2 days. Parental background factors included age, socioeconomic status, current use of prescribed medicines and the use of OTC medicines and vitamins in the preceding two days. Parental socioeconomic status was identified by asking the parent to report the highest education level from a 7-item list and household net income/month from an 11-item list. The working status of the parent was classified as working or not working (including being unemployed, home with children, retired, studying or on sick leave). The classification of each of these background variables is shown in Table 1. Statistical analyses The data were analysed with SPSS for Windows ver. 14.0 (SPSS, Chigaco, IL). We used cross-tabulation and Pearsons chi-square test as a univariate analysis, when analysing categorical variables. A p value of <0.05 was considered to be statistically significant. For the multivariate analysis, we used logistic regression analyses [odds ratios (ORs) with 95 % confidence interval (CI)] when measuring the factors associated with CAM use among children. Three age groups of children (02, 36 and 711 years) were used, as in the previous population-based study in Finland [19]. In the first model, all of the variables listed in Table 1 were

Eur J Clin Pharmacol (2012) 68:16391645 Table 1 Characteristics of the study sample and the use of CAMs in relation to different background characteristics Characteristics of children/parents Characteristics of the study population (n 0 4,032) Use of CAM

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Significancea

Child Gender Male Female Age (years) 0 2 3 6 711 Birth order First born Second born Third born or more, or twins Number of prescribed medicines used 0 1 2 3 Number of OTC medicines used 0 1 2 Number of vitamins used 0 1 2 Health status Good Fairly good Moderate, fairly poor or poor Number of diseases diagnosed by a physician 0 1 2 Number of symptoms 0 1 2 Parent Age (years) 30 3145 46 Parents highest level of education Junior high school or less (9 years) Senior high school / vocational school (1113 years) Polytechnic, college or university degree ( 15 years) Household net income/month () Below 1999

p 0 0.14 2,106 (52) 1,926 (48) 1,004 (25) 1,287 (32) 1,741 (43) 1,662 (41) 1,325 (33) 1,027 (26) 3,359 (83) 332 (8) 187 (5) 154 (4) 3,384 (84) 547 (14) 101 (3) 2,573 (64) 1,358 (34) 101 (3) 3,249 (81) 631 (16) 135 (3) 3,281 (82) 559 (14) 169 (4) 1,353 (34) 1,298 (33) 1,334 (34) 251/2,067 (12) 201/1,891 (11) p 0 0.08 121/981 (12) 124/1,269 (10) 207/1,708 (12) p <0.001 220/1,632 (14) 144/1,298 (11) 88/1,011 (9) p <0.001 342/3,311 (10) 52/320 (16) 31/177 (18) 27/150 (18) p 0 0.04 360/3,314 (11) 79/543 (15) 13/101 (13) p <0.001 216/2,515 (9) 203/1,342 (15) 33/101 (33) p <0.001 329/3,200 (10) 94/610 (15) 27/132 (21) p <0.001 342/3,255 (11) 76/538 (14) 32/164 (20) p <0.001 106/1,329 (8) 138/1,281 (11) 206/1,303 (16) p 0 0.63 862 (22) 2,866 (72) 256 (6) 252 (6) 2,456 (61) 1,291 (32) 797 (21) 89/843 (11) 331/2,817 (12) 28/252 (11) p 0 0.001 15/241 (6) 259/2,412 (11) 174/1,275 (14) p 0 0.44 87/774 (11)

1642 Table 1 (continued) Characteristics of children/parents 2,0002,999 3,0003,999 4,00010,000 Working status Working Not working Number of prescribed medicines used 0 1 2 3 Number of OTC medicines used 0 1 2 Number of vitamins used 0 1 2 Number of CAMs used 0 1 2
a

Eur J Clin Pharmacol (2012) 68:16391645

Characteristics of the study population (n 0 4,032) 1,292 (34) 1,419 (37) 347 (9) 2,541 (63) 1,470 (37) 2,429 (61) 869 (22) 400 (10) 302 (8) 2,949 (73) 938 (23) 145 (4) 2,697 (67) 1,029 (26) 306 (8) 3,271 (81) 624 (16) 137 (3)

Use of CAM

Significancea

137/1,270 (11) 178/1,399 (13) 42/341 (12) p 0 0.79 284/2,497 (11) 168/1,441 (12) p 0 0.05 267/2,392 (11) 114/855 (13) 32/392 (8) 37/293 (13) p 0 0.29 322/2,895 (11) 117/921 (13) 13/142 (9) p <0.001 217/2,642 (8) 162/1,013 (16) 73/303 (24) p <0.001 203/3,206 (6) 179/617 (29) 70/135 (52)

Significance according to the Pearson chi-square test

Data are presented as the number (of children/parents), with the percentage (proportion) given in parenthesis CAMs, Complementary and alternative medicines; OTC, over-the-counter

included. However, several of these were found to be nonsignificant and therefore removed using a backward stepwise process. The final model was adjusted for childs age (Table 2). The discriminating ability of the analysis was measured by receiver operating characteristic (ROC) curve analysis, which indicated that the discriminating ability was good for the use of CAM [area under the ROC curve (AUROC) value 0.79]. We analysed the complementary and alternative use of CAM among children by cross-tabulation, and the results are shown as percentages and frequencies (Table 3).

Results Characteristics of the study sample The study sample consisted of 5,992 children because the parents of eight children could not be reached by mail. In total, 4,121 questionnaires were returned after two reminders. However, 89 questionnaires were excluded because they were

filled out on behalf of a child that did not belong to the initial study sample. Thus, the final study sample included 4,032 children, yielding a response rate of 67 %. The characteristics of the study sample are described in Table 1. We analysed the representativeness of the respondents and non-respondents compared with the target population. The analysis showed that the study sample was representative of the target population in terms of age and gender of the child. Minor differences were found in the regional distribution: southern, 40.7 % (the actual proportion of the children in that area is 41.1 %); western, 32.6 % (34.9 %); eastern, 12.8 % (9.9 %); Oulu region, 10.1 % (10.4 %); Lapland, 3.4 % (3.3 %); land 0.5 % (0.5 %). However, analysis of the non-respondents showed no significant differences compared with the target population in terms of age, sex or regional distribution [19]. The use of CAMs among children In total, 11 % of children had used a CAM in the preceding 2 days. The use was equally common in all age groups and

Eur J Clin Pharmacol (2012) 68:16391645 Table 2 Logistic regression analysis of the factors associated with CAM use among children (n 0 4,032)a Factors associated with CAM use among children/parents Child Birth order First born Second born Third born or more, or twins Number of symptoms 0 1 2 Number of vitamins used 0 1 2 Parent Number of prescribed medicines used 0 1 2 3 Number of vitamins used 0 1 2 Number of CAMs used 0 1 2 Use of CAM among children

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1.00 0.77 (0.600.99) 0.62 (0.470.83) 1.00 1.34 (1.001.78) 1.94 (1.482.55) 1.00 1.52 (1.191.94) 2.83 (1.694.74)

education of a parent and the parental use of vitamins and CAMs predicted the CAM use among children. The use of CAMs among children was least frequent if the parent was using two prescribed medicines. In the multivariate analysis, when adjusted with other variables, only the child being first born, number of symptoms and a number of vitamins being used by the child were associated with CAM use (Table 2). Of the parental factors, the use of one or more vitamins and CAMs remained associated with the use of CAMs among children. The use of CAMs was least common among children with a parent who used two prescribed medicines. Complementary and alternative use of CAMs In the preceding 2 days, 3 % of the children had used only CAMs, 38 % had used only prescribed medicines or OTC medicines and 7 % used CAMs in conjunction with prescribed medicines and/or OTC medicines (Table 3). The use of only CAMs was most common among 7- to 11-year-old children. In contrast, the use of only prescribed medicines and/or OTC medicines and the use of both CAMs and prescribed medicines and/or OTC medicines together were most common among children under 3 years of age (Table 3). The use of CAMs only was most common among children who did not have any diseases diagnosed by a physician. In contrast, the use of prescribed medicines and/or OTC medicines only, and the complementary use of CAM and prescription medicines and/or OTC medicines increased with the number of diseases and symptoms (Table 3).

1.00 0.97 (0.751.26) 0.53 (0.350.80) 0.73 (0.491.11) 1.00 1.49 (1.171.91) 1.44 (1.012.05) 1.00 5.81 (4.577.37) 14.04 (9.4120.94)

Data are reported as the odds ratio (OR) with the 95 % confidence interval (CI) given in parenthesis
a

Discussion The results of our study indicate that CAMs are used mainly for improving health and alleviating symptoms. One in ten of the children participating in the survey used some CAMs, especially fish oils and fatty acids or probiotics. Fish oils and echinachea have been reported also to be widely used among children in the USA [7], whereas homeopathics have been reported to be the most commonly used in the Netherlands, England and Italy [2, 3, 20], with herbal medicine use being the most common in South Australia [21]. CAM use among our Finnish paediatric study cohort was mainly complementary rather than alternative to conventional medicine. A similar finding was reported in a study among paediatric patients in Wales where the majority of herbal medicine users also used prescription medicines [11]. The widespread use of fish oils and fatty acids among Finnish children indicate that CAMs are primarily used as a means of maintaining or improving health. Some studies have shown that fish oils and fatty acids have positive

Adjusted for childs age

among both genders (Table 1). Fish oils and fatty acids (6 % of children) and probiotics (4 % of children) were the most common preparations given to a child. Homeopathics had been used by 1 % of the children, and other CAMs by 3 %. Patterns of CAM use among children The univariate analysis revealed several factors to be associated with CAM use among children (Table 1). The use of CAM was most common among first-born children, and it was found to be more common among children who used at least one or more prescribed medicines, OTC medicines or vitamins. Children who used CAMs were more likely to have a moderate or poor health status, at least one disease diagnosed by a physician and one or more symptoms reported by their parent. Of the parental factors, high

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Table 3 The use of only CAM products, prescription medicines and/or OTC medicines and the concomitant use of CAM products and prescription medicines and/or OTC medicines Factors associated with CAM use among children Age (years), (n 0 4,004) 02 36 711 Total Number of diseases diagnosed by a physician (n 0 3,981) 0 1 2 Number of current symptoms (n 0 3,959) 0 1 2 Use of only CAM products, i.e alternative use Use of only prescribed and/or OTC medicines Use of CAM and prescribed and/or OTC medicines, i.e complementary use p <0.001 105 (11) 64 (5) 96 (6) 265 (7) p <0.001 175 (5) 61 (11) 27 (16) p <0.001 37 (3) 76 (6) 151 (11)

p <0.001 8 (1) 37 (3) 83 (5) 128 (3) p 0 0.029 116 (4) 10 (2) 2 (1) p 0 0.25 49 (4) 44 (3) 34 (3)

p <0.001 591 (59) 451 (35) 480 (28) 1522 (38) p <0.001 1,064 (33) 331 (60) 115 (68) p <0.001 329 (25) 522 (40) 661 (50)

Data are presented as the number (of children/parents), with the percentage (proportion) given in parenthesis
a

Significance according to the Pearson chi-square test

effects on the development of children and on the ability to concentrate [22, 23]. Since the number of symptoms was associated with the use of CAMs among children, CAMs may partly be used for symptom treatment such as the use of probiotics for treating symptoms of infantile colic [24] or antibiotic-associated diarrhoea [25]. Our findings are consistent with those of previous studies reporting that CAM use is common in children when at least one of the parents also uses CAMs [27]. We found that CAM use among children was also more likely if the child was the first born. Less experienced parents may worry more about their childs health than more experienced ones [26, 27] and thus may take extra precautions. The multivariate analyses did not reveal any significant association between parental education or income and CAM use among children following adjustment of other variables. However, such an association has been found in many previous studies [58, 10, 21]. One of the reasons for this difference may be differences in cultures and regulations regarding CAM providers in different countries [28, 29]. Developing and developed countries differ with respect to their regulations on CAM providers: in Germany, for example, most of the CAM providers, especially of homeopathics, are physicians [28]. High parental education has been found to predict the use of homeopathics among children [30, 31]. In Finland, however, homeopathy has not been a part of conventional care [20, 29], and its use is also rare among children, as shown in our study. The safety of CAM use is an important issue because the effects may not be known or be predictable. In our study,

there was no significant association between the use of prescribed or OTC medicines and CAM use in the multivariate analyses. However, most of the CAM users also used conventional medicines. In addition, when our findings on CAM use among children were compared with those of a previous Finnish study, there has been a slight increase in the use of CAM among children during the last decade [16]. This implies that healthcare professionals should be attentive when prescribing medicines or recommending selfmedication and should ask about CAM use in the paediatric patient. Another reason why this is important is that it has been found that parents seldom inform their physicians about the use of CAM by their children [2, 5, 9, 10]. The findings of our study mainly confirm those of previous studies. However, the major strength of our study is that it explored the CAM use in the general paediatric population. Moreover, to the best of our knowledge, the use of CAM in conjunction with prescribed medicines has not previously been widely studied, especially among the general population. We used a similar set-up to that used in a previous study in Finland, with a short recall period covering the preceding 2 days [16] as this approach decreases the possibility of recall bias and also increases the reliability of our results. However, the use of prescribed medicines was identified according to current use. Even though prescribed medicines are typically used regularly or as a course, we do not know whether the concomitant users of CAMs and prescribed medicines had taken prescribed medicines during the same 2-day recall period. A slight upward trend in CAM use among Finnish children has been seen during the last

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1645 parents of children with HIV infection and asthma and well children. South Med J 98(9):869875 Sidora-Arcoleo K, Yoos H, McMullen A, Kitzman H (2007) Complementary and alternative medicine use in children with asthma: prevalence and sociodemographic profile of users. J Asthma 44:169175 Tomlinson D, Hesser T, Ethier M-C, Sung L (2011) Complementary and alternative medicine use in pediatric cancer reported during palliative phase of disease. Support Care Cancer 19:1857 1863. doi:10.1007/s00520-101-1029-0 Arinen S, Hkkinen U, Klaukka T et al (1998) Health and the use of health services in Finland: main findings of the Finnish Health Care Survey 1995/96 and changes from 1987. Stakes and Kela, SVT Health Care, Helsinki Goldman RD, Rogovik AL, Lai D, Vohra S (2008) Potential interactions of drugnatural health products and natural health products natural health products among children. J Pediatr 152:521526 Ylinen S, Hmeen-Anttila K, Sepponen K, Kettis-Lindblad , Ahonen R (2010) The use of prescription medicines and selfmedication among childrena population-based study in Finland. Pharmacoepidemiol Drug Saf 19:10001008 Klaukka T, Martikainen J, Kalimo E (1990) Drug utilization in Finland 19641987. Publications of the Social Insurance Institution, Helsinki Sanz E, Bush P, Garcia M et al (1996) The contents of medicine cabinets in eight countries. In: Bush P, Trakas D, Sanz E et al (eds) Children, medicines, and culture. Pharmaceutical Products Press, New York, London, pp 77101 Smith C, Eckert K (2006) Prevalence of complementary and alternative medicine and use among children in South Australia. J Pediatr Child Health 42:538543 Kirby A, Woodward A, Jackson S, Wang Y, Crawford MA (2010) Childrens learning and behaviour and the association with cheek cell polyunsaturated fatty acid levels. Res Dev Disabil 31:731742 Ryan AS, Astwood JD, Gautier S, Kuratko CN, Nelson EB, Salem N (2010) Effects of long-chain polyunsaturated fatty acids supplementation on neurodevelopment in childhood: A review of human studies. Prostaglandins Leukot Essent Fatty Acids 82:305314 Savino F, Pelle E, Palumer E et al (2007) Lactobacillus reuteri (American Type Culture Collection strain 55730) versus simethicone in the treatment of infantile colic: a prospective randomized study. Pediatrics 119(1):124130 Vanderhoof JA, Whitney DB, Antonson DL et al (1999) Lactobacillus GG in the prevention of antibiotic-associated diarrhea in children. J Pediatr 135(5):564568 Birchley N, Conroy S (2002) Parental management of over-thecounter medicines. Pediatr Nurs 14(9):2428 Lagerlv P, Helseth S, Holager T (2003) Childhood illnesses and the use of paracetamol (acetaminophen): a qualitative study of parents management of common childhood illnesses. Fam Pract 20(6):717723 World Health Organization (WHO) (2001) Legal status of traditional medicine and complementary/alternative medicine: a worldwide review. Available at: http://whqlibdoc.who.int/hq/ 2001/WHO_EDM_TRM_2001.2.pdf Accessed 23 Feb 2011 Jonsson PM (2007) Vaihtoehtoiset ja tydentvt hoitomuodot pohjoismaisessa lainsdnnss. Suom Laakaril 26(62):2573 2577 Wirsing R (1996) The use of conventional and unconventional medicines to treat illnesses of German children. In: Bush P, Trakas D, Sanz E et al (eds) Children, medicines, and culture. Pharmaceutical Products Press, New York, London, pp 77101 Du Y, Knopf H (2009) Paediatric homoeopathic in Germany: results of the German Health Interview and Examination Survey for Children and Adolescents (KiGGS). Pharmacoepidemiol Drug Saf 18:370379

decade [16], and it is very possible that the prevalence of CAM use has increased since 2007 when this study was conducted. In conclusion, our results show that CAMs are used among Finnish children mainly for maintaining and improving health and for treating symptoms. This was especially so in families where at least one of the parents used these remedies themselves. Furthermore, CAM use among Finnish children seems to be complementary rather than as an alternative to conventional care.
Acknowledgements This study received no specific grant from any funding agency in the public, commercial or non-profit sectors. The study was conducted by the School of Pharmacy, University of Eastern Finland, Kuopio, Finland. All costs were covered by the School of Pharmacy. Conflict of interest The authors declare that they have no conflict of interest.

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