Herbs Every Pediatrician Should Know

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Herbs Every Pediatrician Should Know

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

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Disclaimer

• 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
  anticipated.
• 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
  presentation.

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Objectives

• 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
  use
• 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

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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

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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?

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Asking patients

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

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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,
  chamomile

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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

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Herbs and Medication - differences

• Processing
• Purity
• Potency
• Politics/ regulation
• PR perceptions, marketing
• Power of advertising impact on peer review

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1994 DSHEA on food supplements

• 1. Supplements can be marketed without testing
  efficacy.
• 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
  evidence.
• 6. FDA approval not needed for marketing claims.
• More recent requirements for GMP
• FTC has cracked down on marketing more in last 5
  years.
• Report adverse effects to FDA MedWatch
• test.fda.gov/medwatch/

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http//www.fda.gov/downloads/Safety/MedWatch/HowTo
Report/DownloadForms/ucm082725.pdf
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Toxicity

• 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

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Safety Summary

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

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IF YOU BUY HERBS,

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

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Skin

• 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?

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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

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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
  contractions?

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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

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Aloe - bottom line

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

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Nervines

• 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

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Chamomile

• 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
  dose)

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Chamomile - Biochemistry/ Active Ingredients

• chamazulene
• alpha-bisapolol
• apigenin
• flavonoids and other antioxidants

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Chamomile - Scientific Evidence

• apigenin binds GABA receptors - like many
  sedatives
• 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

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Other herbal sedatives

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

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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

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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

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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

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Stress, part 2

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

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Green tea

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

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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
  cough.
• What herbal remedies does evidence suggest MIGHT
  be helpful (safe for most people) to boost immune
  function?

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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)

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Echinacea- Botany

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

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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

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Echinacea - Scientific Evidence

• E. purpurea extracts taken daily in high doses
• reduce the number of cold and flu symptoms in
  adults
• 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

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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
  symptoms
• Zakay-Rones Z. J Int Med Res, 2004
• Barak V. Isr Med Assoc J, 2002
• Vlachojannis JE, Phytother Res. 2010

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Ginseng

• 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.
  2009
• Vohra S. Pediatrics, 2008

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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

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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

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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

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Feverfew - Scientific Evidence Migraines

• Parthenolide reduces platelet activation
• P. prevents release of arachidonic acid and
  serotonin, reducing prostaglandin-mediated
  inflammation
• 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

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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

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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)

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St Johns Wort

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

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Resources

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

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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
  form.
• 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
  www.aap.org/sections/chim/

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Extra Info Slides
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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

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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
• AVOID HERBAL PRODUCTS FROM DEVELOPING COUNTRIES

MMWR, 2004 Occup Environ Med, 1998
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Also for Depression

• Saffron
• Studies from Iran suggest it is as effective as
  antidepressant medications with fewer side
  effects
• Expensive to get the real thing
• No insurance coverage

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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
  antibiotics
• Neuroprotective effects (Alzheimers prevention?)
• Absorbed better with oil and black pepper
• Safety causes biliary contractions (avoid if
  stone history) inhibits platelet aggregation