Herbs Every Pediatrician Should Know - PowerPoint PPT Presentation

1 / 50
About This Presentation

Herbs Every Pediatrician Should Know


Herbs Every Pediatrician Should Know Kathi J Kemper, MD, MPH Director, Center for Integrative Medicine Professor of Pediatrics and Public Health Sciences – PowerPoint PPT presentation

Number of Views:352
Avg rating:3.0/5.0
Slides: 51
Provided by: MAN70


Transcript and Presenter's Notes

Title: Herbs Every Pediatrician Should Know

Herbs Every Pediatrician Should Know
  • Kathi J Kemper, MD, MPH
  • Director, Center for Integrative Medicine
  • Professor of Pediatrics and Public Health
  • Wake Forest University Health Sciences

  • I have the following financial relationships with
    the manufacturer(s) of any commercial product(s)
    and/or provider of commercial services discussed
    in this CME activity
  •         American Academy of Pediatrics, Mental
    Health, Naturally Author. Royalties
  • The presentation will include no description of
    any proprietary items for screening, diagnosis,
    or treatments.
  • I do not intend to discuss an unapproved or
    investigative use of a commercial product in my

  • By the end of this presentation, participants
    will be able to
  • Describe the role of herbal medicine in the
    overall scheme of health care
  • Identify at least one herbal product they already
  • Confidently and effectively ask patients about
    their use of herbal products
  • Use evidence-based resources to advise patients
    about the safe and effective use of herbal
    products and report adverse events

Integrative Approach herbs role?
  • Lifestyle Environment, Exercise/Sleep,
    Nutrition, Mind-Body
  • Supplements, including herbs vitamins, minerals,
    amino acids, hormones, medications
  • Massage, PT, chiropractic, osteopathic, surgical
    and other biomechanical approaches
  • Biofield therapies

Role of herbs ask all
  • NOT a replacement for fundamentals
  • May be a useful adjunct if used wisely
  • Patients may be using ask!
  • What is this patient ALREADY taking???? Ephedra?
    Laxative herbs? Diuretic herbs? Stimulant herbs?

Asking patients
  • By show of hands, how many people in this room
    use an herbal product 4 days weekly to achieve
    a health goal?

Common, unconscious
  • When you ask, give examples!
  • For example, coffee, tea, commonly used products
    for age/gender/condition
  • For children - echinacea, goldenseal, elderberry
  • For men - saw palmetto
  • For women - cranberry, vitex, black cohosh
  • For elderly - ginkgo
  • Unique cultural/ethnic traditions - garlic,

Be Safe!
  • Ask all patients and document the product,
    ingredients and manufacturer in medical record
  • Herb-drug interactions can occur
  • 94 DSHEA means little consumer protection
    marked variability in purity and potency
  • Use caution during pregnancy, lactation and
    infancy, and with other biochemical remedies
  • Opportunity costs - using herbs when another
    approach would be more cost-effective and safer
  • M Cirigliano, JAMA, 19982801565-6

Herbs and Medication - differences
  • Processing
  • Purity
  • Potency
  • Politics/ regulation
  • PR perceptions, marketing
  • Power of advertising impact on peer review

1994 DSHEA on food supplements
  • 1. Supplements can be marketed without testing
  • 2. Safety need not be proved before marketing.
    Burden is on FDA to prove product is unsafe.
    (Ephedra was banned in 2004 after YEARS after
    reports of deaths)
  • 3. Standards not required for manufacture.
  • 4. Structure/function product claims allowed.
  • 5. Label claims do not require extensive
  • 6. FDA approval not needed for marketing claims.
  • More recent requirements for GMP
  • FTC has cracked down on marketing more in last 5
  • Report adverse effects to FDA MedWatch
  • test.fda.gov/medwatch/

  • Herbs themselves direct (eg allergies or rashes
    from echinacea)
  • Natural variability
  • Wrong or diluted product
  • Wrong dose (Excessive ephedra)
  • Manufactured NOT customary (kava)
  • Heavy metals (Ayurveda, Mexican, Asian -
    melamine, anyone?)
  • Drugs intentional spiking

Safety Summary
  • Herbs are not necessarily safe just because
    theyre natural
  • Herbs work biochemically
  • FDA regulation needed to assure purity/potency

  • Manufacturer has base in Germany, France or
  • Label
  • Scientific (Latin species) name of plant
  • standardized extract
  • expiration date, lot
  • source (leaves, root, flower, etc.)
  • Local manufacturer whose plant you have visited?

  • You have just spent a little too much time in the
    sun, getting your vitamin D and enjoying the
    pools and beach
  • Skin is red, not blistered
  • What herbal product can you use to help relieve
    the pain and promote healing?

Aloe vera - History and Common uses
  • used by Egyptians (Cleopatras beauty secret?),
    Greeks, Chinese, Ayurveda, S. Africa, S. America
  • Used for
  • burns and skin irritations
  • ulcers, canker sores
  • laxative

Aloe - active ingredients
  • glucomannan - emollient polysaccharide
  • carboxypeptidase - bradykininase, reduces pain
  • magnesium lactate zinc, calcium, glucose,
    cholesterol, triglycerides
  • salicylic acid and other anti-prostaglandin/
    anti-thromboxane compounds
  • acemannan - immune stimulator
  • aloin or barbaloin- strong laxative uterine

Aloe - scientific evidence of effectiveness
  • minor burns and wound healing, comparable to
    Silvadene good antibacterial properties
  • acemannan stimulates killer T cells and fights
    viral replication, including HIV increases WBC
    in HIV infected persons no studies on aloe
    affecting AIDS clinical course
  • preliminary studies suggest potential use in
    duodenal ulcer, canker sores
  • barbaloin, aloin are potent cathartics

Aloe - bottom line
  • good for home treatment of minor wounds including
    burns, scrapes, etc.
  • possibly useful for canker sores
  • very safe for external use

  • You have just had a rough day at the office. You
    come home and try to decide which herbal product
    might help you relax. Assuming you arent
    allergic to any, which of the following herbal
    remedies is safest?
  • A. Beer
  • B. Whiskey
  • C. Chamomile/lemon balm tea
  • D. Kava kava

  • Mild anti-inflammatory
  • Mild sedative (stress, insomnia)
  • Mildly relaxes intestinal spasms (colic)
  • Yes, Peter Rabbits mother was on to something (1
    Tablespoon to be taken before bedtime - rabbit

Chamomile - Biochemistry/ Active Ingredients
  • chamazulene
  • alpha-bisapolol
  • apigenin
  • flavonoids and other antioxidants

Chamomile - Scientific Evidence
  • apigenin binds GABA receptors - like many
  • RCT of essential oil fragrance in young adults
    signif. calming
  • Case series10/12 hospitalized patients drinking
    c. tea slept
  • Helps rats sleep
  • Shinomiya K. Biol Pharm Bull, 2005
  • Good for stressed cows, too
  • Reis LS. J Vet Sci, 2006

Other herbal sedatives
  • Valerian (sleep aid), hops, lemon balm,
    passionflower (anxiety), skullcap
  • All recommended by German commission E to treat
  • Low risk
  • Often found in combination products
  • NOT processed kava kava - potent liver toxicity

Valerian - Smelly soporific
  • Galen used to treat seizures
  • 1700s - sedative, anti-spasmodic
  • WW1 - treat shell shocked soldiers anti-anxiety
  • 120 chemical constituents potency varies by
    species and wanes over time
  • GABA receptors positive effects in mice and men
  • Helpful for sleep, anxiety

Valerian - Scientific Evidence anxiety and sleep
  • RCT of 40 anxious adults 100 mg TID X 21 d,
    signif improved sx compared with placebo
  • DB X-over study of 128 insomniac adults, 400 mg
    qhs -gtsignif improvement in sleep onset compared
    with placebo
  • Comparison study of 450 mg qhs shorter sleep
    onset and no hangover
  • Young adults 450 mgs qhs shorter sleep onset and
    better quality of sleep than placebo

Valerian - Toxicity/Side Effects
  • Very safe even in those whove taken huge
    intentional ODs
  • Mild side effects - headaches, restlessness
  • No apparent addictive or dependent qualities no
    interaction with EtOH

Stress, part 2
  • You like caffeine, but want to avoid the
    jitteriness and irritability. What else might you
  • WHY?

Green tea
  • Theanine (amino acid)
  • Counteracts negative effects of caffeine without
    making you sleepy
  • Kimura K. Biol Psychiatry, 2007

Immune Function
  • You are seeing a patient for a health supervision
    visit (check-up). She is starting to develop cold
    symptoms, and has taken vitamin C and zinc
    lozenges, and plans to make some chicken soup.
  • She washes her hands, sleeps well and covers her
  • What herbal remedies does evidence suggest MIGHT
    be helpful (safe for most people) to boost immune

Immune boosters?
  • Echinacea - maybe (I do)
  • Elderberry (brand tested has been Sambucol) -
    maybe (I do)
  • Ginseng (brand tested has been Cold-FX) - maybe
    (I do)
  • Astragalus - maybe (I dont)

Echinacea- Botany
  • Activity varies by species, part used, harvest
    timing, preparation, storage
  • MANY different constituents

Echinacea - Scientific Evidence Immune System
  • Polysaccharides increase WBCs released from
    bone marrow activate phagocytosis enhance
    production of TNF, interferon, interleukeins 1
    and 6
  • Inulin stimulates alternative complement pathway

Echinacea - Scientific Evidence
  • E. purpurea extracts taken daily in high doses
  • reduce the number of cold and flu symptoms in
  • reduce the number of colds acquired by adults
  • No benefits on cure kids may help prevention
  • Safety - some allergies (skin rashes)
  • Linde K. Cochrane Database Rev, 2006
  • Weber W. J Alt Comp Med, 2005
  • Taylor JA. JAMA, 2003

Elderberry (Sambucol)
  • used in folk medicine to treat influenza, colds
    and sinusitis
  • has antiviral activity against influenza and
    herpes simplex
  • RCT of adults with lt 48 hours influenza symptoms
    given 15 mL QID, significantly reduced length of
  • Zakay-Rones Z. J Int Med Res, 2004
  • Barak V. Isr Med Assoc J, 2002
  • Vlachojannis JE, Phytother Res. 2010

  • 5 Canadian studies including gt 700 adults of
    Cold-FX, suggest it can help PREVENT and reduce
    duration (by nearly 6 days) of viral respiratory
    infections in adults
  • 1 study shows it is feasible to give to children
  • Seida JK. Evid Based Complement Alternat Med.
  • Vohra S. Pediatrics, 2008

Case Migraines
  • 17 year old with recurrent migraines. She keeps a
    headache diary, avoids triggers, gets enough
    sleep she has started B2 supplements, 5-HTP
    supplements, fish oil is thinking about massage
    and acupuncture. She does not want to take drugs.
  • Which herbal supplements might be helpful?
  • Ginger for nausea
  • Feverfew - for prevention
  • Butterbur (UPA-free)
  • All of the above

Ginger (Zingiber officinale)
  • related to turmeric and cardamom
  • contains shogoal, gingerols (sesquiterpenes),
    bisabolene, zingiberene, zingiberol
  • RCT effects on nausea and vomiting with chemo,
    motion sickness, pregnancy, post-op
  • Safe- rare allergies, upset stomach
  • Dose 500 - 1000 mg/QID or tea ad lib
  • White B. Am Family Phys, 2007

Feverfew Tanacetum parthenium
  • Purity and potency vary markedly between
    products British gt American products in general
    higher with spring harvest look for at least
    0.2 parthenolide content
  • 3 RCT show 25-50 mg daily help prevent migraines
  • Safety 10 mouth sores rebound if stopped
  • Tepper SJ. Curr Pain Headache Rep, 2008

Feverfew - Scientific Evidence Migraines
  • Parthenolide reduces platelet activation
  • P. prevents release of arachidonic acid and
    serotonin, reducing prostaglandin-mediated
  • P. reduces damage to microvessel walls
  • 3 RCT in humans show that 2-3 fresh leaves (25-50
    mgs BID of dried leaves) effectively prevent
    migraine, and rebound HA when leaves stopped
  • NOT effective in treating HA acutely

Butterbur (Petadolex)
  • 2 RCTs before 2006 293 adults 150 mg daily
    showed benefits, but not 100 mg daily
  • 2008 German RCT in children showed positive
    prophylactic effect (brand used in most studies
    is Petadolex)
  • Must be UPA-free!
  • Oelkers-Ax R, Eur J Pain, 2008
  • Sadler, Pediatrics in Review, 2007
  • Oelkers-Ax R. Eur J Pain, 2008
  • Agosti R. Phytomedicine, 2006
  • Pothman R. Headache, 2005

Depression case
  • 15 year old landscaper with recurrent depression
    gets plenty of exercise poor sleep junk food
    junky, unwilling to change just broke up with
    girlfriend lost his job
  • Is St. Johns wort a good idea?
  • (Note if he asks you, hes probably already
    using it. Ask about which brands hes tried and
    what hes already read on the internet)

St Johns Wort
  • Depression possibly effective 300 mg three
    times daily http//nccam.nih.gov/health/stjohnswor
  • Sunburn
  • Interferes with many other medicines
  • Which brands contain what they say they do?
  • http//www.consumerlab.com/results/sjw.asp

  • Free
  • NIH MedLine Plus
  • WFUBMC - BestHealth
  • Subscription, but worth it
  • Natural Medicines Comprehensive Database
  • Natural Standard
  • ConsumerLab.com

Suggested Practice Changes
  • Try drinking green tea to see how it affects you
  • Try an aloe product on your next sunburn or
    canker sore.
  • Try using echinacea, ginseng, or elderberry for
    your next cold
  • Ask at least 50 of patients in the next week
    about their use of herbs
  • Advise your patients who use herbal products to
    avoid herbal products from developing countries
  • Ask your assistant to print out the FDA MedWatch
  • Subscribe to an herbal information resource for 1
    year to see how useful it is in your practice.
  • Join the AAP SOCIM (tsalus_at_aap.org or

Extra Info Slides
Product variability - ginseng
  • 25 commercial products analyzed
  • All products contained species listed on label
  • Ginsenoside concentrations varied 15 and 36 fold
    in capsules and liquids, respectively
  • Eleutheroside concentrations varied 43- and 200-
    fold in caps and liquids respectively
  • Harkey, et al. Am J Clin Nutr, 2001

Heavy metals in folk remedies
  • Lead (12 cases in US in 2002-2003 from Ayurvedic
    herbs from India)
  • Mercury in TCM
  • Arsenic and Mercury in Chinese herbal balls

MMWR, 2004 Occup Environ Med, 1998
Also for Depression
  • Saffron
  • Studies from Iran suggest it is as effective as
    antidepressant medications with fewer side
  • Expensive to get the real thing
  • No insurance coverage

Curcumin (Turmeric)
  • Anti-inflammatory (inhibits LOX and COX-2)
  • Antioxidant free radical scavenging
  • 19 ongoing clinical trials for chemoprevention of
    cancer may reduce multi-drug resistance and
    protect normal cells
  • Increases antibacterial effects of commonly used
  • Neuroprotective effects (Alzheimers prevention?)
  • Absorbed better with oil and black pepper
  • Safety causes biliary contractions (avoid if
    stone history) inhibits platelet aggregation
Write a Comment
User Comments (0)
About PowerShow.com