Herbs are helpful, but use with caution in children

More and more parents are using herbal medications to manage their children’s health conditions, but which ones are safe and how are they used?

Cora Collette Breuner, MD, MPH, FAAP, professor of Pediatrics and Adolescent Medicine and adjunct professor of Orthopedics and Sports Medicine at Seattle Children’s Hospital and the University of Washington, Seattle, presented trends on herbal medications in children and uses and guidelines for some of the most popular herbs at the session “Top 10 herbs: Are they safe in kids?” at the American Academy of Pediatrics (AAP) 2017 National Conference and Exhibition on September 17.

Breuner says pediatricians have to be aware of which herbs and supplements parents are giving their children. “About 12% of families use herbs and supplements for their children and that number rises over 50% in those children with chronic illness,” she says.

“Hopefully from this talk, attendees gained an understanding of not only the number of supplements patients and families use but also about safety regulations regarding making sure the products are not contaminated and consistently packaged with standard dosing,” Breuner says.

Breuner presented data from the 2012 National Health Interview Survey (NHIS) that showed the top herbs and supplements used in children were natural products such as fish oil, melatonin, and probiotics. These were most often used for managing back or neck pain, other musculoskeletal conditions, head or chest colds, anxiety or stress, attention-deficit hyperactivity disorder (ADHD), and insomnia or trouble sleeping, she says. Complementary and alternative medicine (CAM) was most often used in adolescents in the West, Northeast, or Midwest in children of parents with a college education and who use CAM themselves. Also, CAM users often used other prescription medications, according to the presentation.

The use of herbs and other natural products is the most popular use of CAM in children, Breuner says, cautioning that herbal products can go on the market with no testing of efficacy or proof that the products are safe. Supplements can’t claim to cure or prevent disease and also don’t have to be manufactured according to any standards, she says, putting users at risk of receiving contaminated products or experiencing interactions. Providers who are aware of a patient’s use of supplements can help them check for interactions, and any reactions should be reported to the US Food and Drug Administration’s MedWatch program and Poison Control.

Breuner also gave an overview of the most popular herbs and supplements, as well as those that should not be used. Licorice, for example, should not be used for more than 6 weeks and has a number of interactions, particularly with digoxin and furosemide. Ephedra is another supplement that needs caution. Used as an anorexiant and decongestant, ephedra can cause palpitations, myocardial infarction, and even death, she says.

Drug interactions include theophylline, digoxin, and caffeine, and the maximum dose is 100 mg per 24 hours. Other supplements that are not recommended include aconite, aristolochus, belladonna, blue cohosh, borage, broom, calamus, chaparral, coltsfoot, comfrey, germander, life root, lobelia, pennyroyal, poke root, sassafras, skullcap, tansy ragwort, and wormwood. Supplements that require extra caution and that should be discontinued prior to surgery include echinacea, ephedra, garlic, gingko, ginseng, kava, St. John’s wort, and valerian. Risks with these various supplements include cardiac and bleeding complications, as well as sedative effects.

Other popular herbs can be used safely with the proper precautions and when the purity or safety of the supplement is reviewed. Breuner presented data on the following herbs and their uses:

·      Gingko: Used for memory or concentration improvement, confusion, depression, anxiety, headache, and more. Works by promoting perfusion and inhibiting oxidative damage, but may also cause gastrointestinal irritation, headache, bleeding, or contact dermatitis. Dosage is 40 mg up to 3 times daily.

·      Caffeine: Used to reduce drowsiness and restore alertness, and works by acting on calcium and cAMP pathways and on external cell membranes. Adverse effects may include anxiety, nervousness, withdrawal, insomnia, headaches, palpitations, gastroesophageal reflux disease, peptic ulcers, and irritability.

·      Echinacea: Approved for use in Germany for supporting upper respiratory infections, urogenital infections, and wound healing. Works by activating nonspecific T-calls, and may inhibit viral replication while enhancing phagocytosis and natural killer cell activity. Six to 9 mL of expressed juice from the echinacea leaf can be used up to 3 times daily, or 30 to 60 drops of root tincture 3 times daily during an upper respiratory infection. Caregivers should watch for allergic reactions, also individuals who are immunocompromised or who have autoimmune diseases.

·      Zinc: Used for prevention or in reducing the length of the common cold. A dose of 75 mg per day may be used within 24 hours of symptom onset. Adverse effects include nausea and insomnia.

·      Valerian: A mild sedative and sleep aid; up to 400 mg can be given at bedtime. Possible adverse effects include paradoxical anxiety, restlessness, and heart palpitations, with withdrawal symptoms present with long-term use.

·      St. John’s wort: Used to help manage depression and works by inhibiting reuptake of serotonin, monoamine oxidase (MAO), 5 HT, dopamine, noradrenaline, gamma-aminobutyric acid (GABA), and glutamate. Up to 300 mg may be used 3 times daily, but caregivers should watch for interactions with warfarin, digoxin, theophylline, cyclosporine, oral contraceptives, and HIV protease inhibitors. It may also cause decreased platelet aggregation, serotonin syndrome, and photosensitivity.

·      Butterbur: Used to treat migraines, and has an anti-inflammatory effect. Dosage can be 50 to 75 mg daily divided across 2 or 3 doses in children aged 8 to 9 years, and up to 100 to 150 mg in 2 to 3 doses daily for children aged 10 to 17 years. Reactions may include gastrointestinal upset or allergic reaction.

·      Magnesium: Used to regulate a variety of biochemical reactions in the body, including protein synthesis, muscle and nerve function, blood glucose control, and blood pressure regulation. Dose is 300 to 500 mg daily, but is also included in foods such as soybeans and black beans, tofu, seeds, nuts, whole grains, and shellfish. Reactions may include diarrhea, and interactions with bisphosphonates, antibiotics, and diuretics. Magnesium may be reduced by the use of proton pump inhibitors.

·      Melatonin: Used for circadian rhythm disorders and insomnia, melatonin appears to increase the binding of GABA to its receptors by affecting membrane characteristics, not by increasing the number of receptors. Dose is 0.5 mg to 5 mg at bedtime, but may impair glucose utilization and decrease prothrombin activity.

·      Omega-3 fatty acids-docosahexaenoic acid (DHA)/eicosapentaenoic acid (EPA): Used to manage ADHD, depression, heart disease, and for prevention of macular degeneration by reducing serum triglycerides and promoting normal neural and synaptic function. Dose is 5 g of fish oil containing 169 mg to 563 mg EPA and 72 mg to 312 mg of DHA twice daily. Adverse effects may include belching, nosebleeds, nausea, and loose stools.

·      Peppermint: Used for irritable bowel syndrome, colic, nausea, decongestant, cough suppressant, anxiolytic, and topical analgesic for headache and myalgia. Acts as a calcium channel blocker in gastrointestinal smooth muscle, stimulates nerve endings in the nasal mucosa, and triggers cold receptors on the skin. One to 2 enteric-coated capsules of 0.2 mL peppermint oil may be taken 2 to 3 times daily, but reactions can include infantile apnea when used under the nose, heartburn, and mild rectal burning.

·      Arnica: Used for inflammation and immune system stimulation associated with bruises, aches, and sprains. Dose is 2 g of flower heads in 100 mL of water as a poultice, or a tincture with 3 to 10 times dilution with water. Adverse effects can include irritation of mucous membranes, drowsiness, stomach pain, vomiting, diarrhea, and allergic reactions in individuals who are sensitive to the Asteraceae/Compositae family.

·      Chamomile: Used as a sedative, antispasmodic, anti-inflammatory, and wound-healing agent. Can be taken through an infusion of fresh or dried flower heads, typically 2 to 3 teaspoons steeped for 10 minutes in a cup of boiling water up to 3 times daily. Use with caution in those sensitive to ragweed, chrysanthemums, or other members of the Compositae family.

·      Ginger: Used as an antiemetic, to treat nausea, as a circulatory stimulant, and for inflammation. It promotes bile flow to the intestines through contraction of the gallbladder. Dose can be from 2 g to 4 g fresh root daily, or 1.5 mL to 3 mL tincture daily. May cause heartburn, decreased platelet aggregation, or contact dermatitis in sensitive patients.

Pediatricians can check interactions and the safety of herbs and supplements at websites such as ConsumerLab.com and the Natural Medicines Comprehensive Database. Breuner says pediatricians should make sure they are taking a history on herbal use from parents and discussing uses in a nonjudgmental way.