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Use of Complementary and Alternative Medicine by
Children in the United States
Matthew P. Davis, MD;
Paul M. Darden, MD
Arch Pediatr Adolesc Med. 2003;157:393-396.
ABSTRACT
Background Current estimates of pediatric complementary
and alternative medicine (CAM) use range from 10% to 15%.
These estimates are derived from children sampled at
health care facilities, with chronic conditions, and/or
from countries other than the United States.
Objective To provide a population-based estimate of the
prevalence of pediatric CAM use in the United States.
Design We used the 1996 Medical Expenditure Panel Survey
(MEPS), a nationally representative survey of the
noninstitutionalized US population. The survey asks
parents if their children used alternative care
practitioners within the previous year. Our analysis
included children younger than 18 years and accounted for
the complex sampling design of MEPS.
Results Weighted for the US population, pediatric CAM
use was 1.8% (95% confidence interval, 1.3%-2.3%).
Participants who used CAM were found in each age
category, and the mean age was 10.3 years; 76.8% were
white, 54% were female, 32% lived in the West, 66% lived
in a metropolitan statistical area, and 36% lived at 100%
to 199% of the poverty level. Bivariate  2 analysis
shows that CAM use increased with age (P = .006) and
was twice as common in children not living in a metropolitan
statistical area (P = .02).
Conclusions The use of CAM among US children, as measured
by the MEPS, is far less prevalent than has previously been
asserted. With such disparate estimates, future CAM research
efforts would benefit from a consensus regarding what
practices constitute CAM and how these practices should
be measured.
INTRODUCTION
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THE DEFINITION of complementary and alternative medicine (CAM)
is not well established. It is generally accepted to be the
integration of nonallopathic methods into preventive or acute
health care. This definition may include numerous sources of
therapy, including meditation, herbal remedies, and
homeopathy. The use of these therapies has enjoyed a
niche among various cultures for hundreds, indeed
thousands, of years. Partly because many of these
therapies predate methodical scientific trials, the
safety and effectiveness of such treatments have not been
well studied. Given the recent rise in popularity of "natural"
and "holistic" remedies and foods, it seems likely that
growing numbers of children would receive at least part
of their health care through these methods. Indeed, a
recent review of studies of alternative medicine in
children worldwide suggests that the prevalence of CAM
use among children may be growing.1 Despite
this concern on the part of Ernst,1 both the
definitions of what constitutes CAM and the survey
methods used vary among the studies examined, making
comparisons between them difficult. To determine the
importance and impact of CAM on children, an accurate
estimate of its prevalence in the United States is
necessary.2
Current published estimates of CAM use in children range from
8% to 15%.3-10
Unfortunately, most of these studies involved children
who may not be reflective of the general population of
children in the United States. Many of the studies were conducted
in countries other than the United States, where attitudes
toward unconventional therapies may be different.
Additionally, most studies measure CAM use in children
who have chronic conditions or who were sampled at health
care facilities. Faw et al10 surveyed
69 parents of children with cancer in Texas and primarily
examined the use of dietary supplements. Following this
1977 report, children with cancer were interviewed in
Australia (n = 48) and Seattle, Wash (n = 106).5-6 In 1990,
Jensen3 published
a report on Norwegian children's use of a wide variety of
alternative therapies during their experience with atopic
dermatitis or psoriasis. A 1990 report of children from
Australia, New Zealand, and Canada with juvenile
arthritis examined use of copper bands, diet,
chiropractic therapy, acupuncture, and skin creams for
rheumatologic complaints.8 It has
been shown that adults with certain chronic or terminal
diseases (eg, arthritis or cancer) are more likely to
seek alternative methods of treatment.11 This may
also be true among children, especially those with
conditions for which conventional medical treatment proves
inadequate. Estimates of CAM use in these populations are
probably not generalizable to all children.
Two estimates of CAM use in less restrictive pediatric
populations were published in 1994. Verhoef et al9 reported
that 12.7% of 0- to 11-year-olds and 24.4% of 12- to
17-year-olds had consulted an alternative care
practitioner, including chiropractors, within the
previous 6 months. These estimates were based on population-based
survey data collected in rural Alberta, Canada. Spigelblatt
et al12 surveyed
1911 children from a university clinic–based population,
of which 11% had used CAM therapies at some point. The
article concludes that alternative medicine is "an aspect
of child health care that cannot be ignored." The study by Verhoef
et al is the only one that limited its definition of CAM use
to a specific time period as opposed to lifetime (or since
diagnosis) use of CAM therapies.
Previous studies of CAM in children used various measures of
CAM, frequently among highly selected populations and in
cultural settings that may define CAM in different ways.
Our objective was to generate a generalizable
population-based estimate of CAM use among US children
and to describe the demographic characteristics of CAM
users.
METHODS
This report analyzes information from the 1996 Medical Expenditure
Panel Survey (MEPS), Household Component, for which 6262
children were surveyed.13 The MEPS
is designed to provide policymakers, health care
administrators, and others with up-to-date, comprehensive
information about health care use and costs in the United States.
The MEPS collects data on the specific health services that
Americans use, how frequently they use them, the costs, and
payment methods. The MEPS also reports on the cost, scope, and
breadth of private health insurance held by and available to
the US population. The Household Component of the MEPS
contains the core survey data. The 1996 survey
oversampled Hispanic and black families to allow
inferences about these demographic groups.
The 1996 Household Component survey included questions about
the use of unconventional therapies. To determine this usage
for children, parents were shown a card, AP-1, that listed CAM
methods. While parents viewed the card, they were asked the
following question:
In order to get as complete a picture as possible of
all sources of health care, we would also
like to ask about the use of other forms of
health care, including treatment you may have previously
told me about, such as the treatments shown on
this card. Frequently this type of care is
referred to as complementary or alternative
care. During the calendar year 1996, for health reasons,
did (person) consult someone who provides
these types of treatments?13
The AP-1 card includes the following list of treatments:
- Acupuncture
- Nutritional advice or lifestyle diets
- Massage therapy
- Herbal remedies purchased
- Bio-feedback training
- Training or practice of meditation, imagery, or relaxation
techniques
- Homeopathic treatment
- Spiritual healing or prayer
- Hypnosis
- Traditional medicine, such as Chinese, Ayurvedic,
American Indian, etc
- Other treatment
Although the MEPS did not include chiropractic therapies in
this survey question, they are included in other portions of
the survey. To be complete, we chose to liberalize our
estimate of CAM users by including participants who
answered yes when asked, "Was a chiropractic practitioner
used in the previous year?" We justify the addition of
chiropractic therapies because, like other types of
treatments listed above, chiropractic therapies have not
been studied in children, and pediatric use is considered
by many to be unconventional.2
Statistical analysis was done using Stata statistical software,
version 7 (Stata Corp, College Station, Tex). The sampling
design of the MEPS requires adjustments to be made for
clustering and stratification, and our weighted analysis
accounted for this complex design. After calculating the
point prevalence of CAM use among children surveyed for
the 1996 MEPS, bivariate 2 analysis was used to
examine use of CAM according to age category, sex, race,
census region, metropolitan statistical area, and poverty
status. P<.05 was considered significant. The poverty measure
used was the MEPS poverty category variable, which was derived
from family size and income and grouped families in relation
to federal poverty thresholds for that year ($15 911 for
a family of 4 in 1996).14 The
Institutional Review Board of the Medical University of
South Carolina, Charleston, reviewed and approved this
project.
RESULTS
When weighted, the sample of 6262 participants younger than
18 years surveyed for the MEPS represents 71 million children
in the United States. The total number of childhood CAM users
in the sample was 101. This gives an unweighted prevalence of
CAM use of 1.6%. The point-prevalence estimate of CAM use in
US children in 1996 was 1.8% (95% confidence interval,
1.3%-2.3%).
Among children, CAM users are older, with a mean age of 10.3
years compared with 8.5 years in nonusers (P<.001). Of
childhood CAM users, 54.3% were female, 34.5% were aged
15 to 17 years, and 76.8% were white. Nearly 36% lived at
100% to 199% of the poverty level; 66.4% lived in
metropolitan statistical areas, and 31.9% lived in the
West (Table 1).
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Demographic Breakdown
of Children in the 1996 Medical
Expenditure Panel Survey*
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The authors of the MEPS sample design consider statistical
analysis of groups of fewer than 100 participants within
MEPS to be unreliable for estimation purposes. This
constraint, combined with low absolute cell sizes within
categorical variables in this data set, limited our
ability to conclusively define the likely predictors of
CAM use in children. The demographic most strongly associated
with CAM use in children was age category; CAM use increased
with age. With a prevalence of 3.5%, older adolescents used
CAM nearly 4 times more than did children younger than 12
months (prevalence, 0.9%). In fact, children aged 15 to
17 years were 2.6 times more likely to be CAM users than
were all other age categories combined (95% confidence
interval, 1.5-4.5). Also statistically significant was
the difference between rural and urban status (Table 1). These
data showed that the prevalence of CAM use among children
not living in metropolitan statistical areas was twice
that of children living in metropolitan statistical areas
(2.9% vs 1.5%; P = .02).
White children constituted the majority of those using CAM,
with a prevalence of 2.1%. Although not statistically
significant when all races were included, the prevalence
among black children (0.8%) was less than half of that
among white children. Another large but not statistically
significant difference among CAM users compared with
nonusers was the percentage of children living at 100% to
199% of the poverty level. Of this group, 2.8% used CAM
in 1996, a rate nearly twice that of the other poverty
categories. Data broken down by region within the United
States showed that CAM use was highest in the West (2.4%) and
lowest in the Northeast (0.9%).
An additional analysis of pediatric CAM use in relation to
parental CAM use was also performed. Seventy-one percent
of CAM-using children had a CAM-using parent.
Additionally, the prevalence of CAM use among children
whose parents used CAM was 9.9%, compared with 0.6% among
children whose parents did not use CAM (P<.001).
The proportion of childhood CAM use in this estimate that is
attributable to the use of chiropractic therapies is
substantial. When users of chiropractic therapies were
excluded from the estimate, the weighted point prevalence
fell from 1.8% to 1.2% (95% confidence interval,
0.8%-1.7%). Once separated out, however, this measure
represented a small and statistically unreliable sample
size (unweighted sample <100).
COMMENT
Recent public interest in CAM could imply an increasing acceptance
and use of these therapies. Based on the data from the 1996
MEPS, CAM use among US children is far lower than previous
surveys have found. In this nationally representative
sample of children, less than 2% reported using CAM in
1996.
The MEPS differs from other estimates of CAM in important ways.
The survey question asks whether participants consulted a CAM
provider in the previous year. This question does not
ascertain use of self-prescribed therapies. All but 1 of
the previous estimates referenced do not make CAM use
contingent on consultation with a provider. Undoubtedly,
differences between definitions of CAM use account for a
portion of the disparity between this and previous
estimates. However, this difference does not explain all
of the disparity between this and previous studies, especially
considering that Verhoef et al9 found
substantially higher rates of CAM use among Canadian
children using a definition similar to that used in the
MEPS.
The MEPS is population based, whereas most other surveys of
CAM use relied on health care facilities to recruit
participants. Previous surveys have used samples that are
likely to overrepresent children with chronic disease and
frequent users of health care.
Finally, the MEPS survey question differs from many other surveys
in its measurement of CAM use in the previous year rather than
lifetime use. Use of CAM in the last year will lead to a lower
estimate of use than a lifetime estimate. However, to the
extent that CAM use varies with the age of the child and
changes over time, this estimate may be more useful in
providing care to children.
These findings have many implications for the way we understand
CAM use among children, both for clinical applications and
future research. The use of CAM by children in the United
States appears to be smaller than previously estimated
when defined by use of an alternative health care
provider. If total childhood CAM therapy use is greater
than this point-prevalence estimate, then a significant
proportion of CAM therapies employed by children in the
United States are outside the guidance of a practitioner.
Pediatricians should be vigilant in seeking out this information
on an individual basis during routine health maintenance
visits.
These findings also have important implications for future
research. The data provide a baseline estimate of CAM use
among children in the United States. Current and future
studies of this kind can now more precisely measure
trends in CAM use, even if defined solely as use of a CAM
practitioner. With regard to the definition of CAM in
future studies, it is relevant to note the difficulty
with which we make conclusions from this data. The MEPS definition
of CAM use undoubtedly misses a significant proportion of the
CAM-using population, among adults as well as children. A
standard measure of CAM use should include use of
practitioners or methods and should unambiguously state
the therapies included in the definition of CAM.
Additionally, biases inherent in questions that poll
different groups should be minimized through use of a
more comprehensive definition that can capture CAM therapies
that may be ethnically associated.
CONCLUSIONS
The 1996 MEPS provides a remarkably low estimate of CAM use
among noninstitutionalized children in the United States—1.8%
during 1996. Despite the low percentage of US children using
CAM therapies in this survey, we should not underestimate the
effect CAM use may have on those children actually engaging
in CAM therapies. Further research is necessary to better
define the populations that are using CAM, as well as the
risks and benefits of individual therapy types. For these
reasons, it is important to standardize our measures of
CAM use so that we can make appropriate decisions for
health care services. This will allow development of
recommendations that can guide pediatric practitioners in
our use of anticipatory guidance in the office setting.
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What This Study Adds
The use of CAM by children in the United
States undoubtedly affects their
health care. Current estimates of
CAM use among children rely on limited
studies. Our analysis helps fill
the gap in our knowledge by offering a
population-based estimate of CAM
use in children.
The extent of the use of CAM
by children remains unclear. The estimate of
use from the MEPS is remarkably
different than estimates from previous
surveys. Our ability to arrive at
evidence-based decisions regarding
CAM use in children is limited by this
apparent discrepancy. Until we
arrive at better measures of CAM use in
children, it will continue to
prove difficult for practitioners to
formulate effective plans for
pediatric health care delivery.
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AUTHOR INFORMATION
Corresponding author: Paul M. Darden, MD, Department of Pediatrics,
Medical University of South Carolina, 326 Calhoun St, PO Box
250106, Charleston, SC 29425 (e-mail:
dardenpm@musc.edu).
Accepted for publication November 27, 2002.
This study was supported in part by grant CFDA 93.895 from the
Bureau of Health Professions, Health Resources and Services
Administration, Rockville, Md.
This study was presented at the Southern Society for Pediatric
Research annual meeting, New Orleans, La, February 21, 2002,
and at the Pediatric Academic Societies annual meeting,
Baltimore, Md, May 4, 2002.
From the Departments of Pediatrics and Biometry and Epidemiology,
the Academic Generalist Fellowship Program, and the Center for
Health Care Research, Medical University of South Carolina,
Charleston.
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