Homeopathy in pediatrics—no harm likely, but how much good?

By Kathi J. Kemper, MD, MPH, and Jennifer Jacobs, MD, MPH

This controversial and little-understood treatment method is one of the most commonly used therapies around the world. Its safety has long been known, and recent research is beginning to shed light on efficacy.

Juan is a 3-year-old with acute diarrhea. He has gushing, painless, watery stools every hour and loud, rumbling, gurgling abdominal noises. He is very thirsty for cold drinks. He is not vomiting, and his mother is doing a good job of keeping him hydrated. She wants to do something more for him but doesn't know whether to give him chamomile tea, as recommended by his grandmother, or a homeopathic remedy recommended by a neighbor. What's the difference between herbal and homeopathic remedies in terms of philosophy, preparation, and product purity?

Fourteen-year-old Ananda is in the intensive care unit because of injuries sustained in a motor vehicle accident, including a hepatic hematoma and rib, pelvic, and femur fractures. He is stable and off the ventilator but has a lot of nausea and vomiting. The resident in the ICU calls you because the boy's parents have asked if they can start giving him the homeopathic remedies arnica and ipecac. The resident is reluctant to give substances that sound so toxic, but the parents insist these remedies are safe. Are they?

Renee is seeing you for her 5-year-old well-child check-up. She had three ear infections last year. Her mother doesn't like the idea of putting her daughter on antibiotics, but she doesn't want her to suffer, either. The mother has already started giving Renee xylitol chewing gum to help prevent ear infections, and she'd like Renee to get a flu shot. She asks you if it's okay to give Renee a homeopathic remedy the next time she starts to get an ear infection rather than coming in to the office for another round of amoxicillin. What's the evidence for using homeopathy as a treatment for otitis media?

Homeopathy is one of the most controversial and least understood of all complementary and alternative medicine (CAM) treatments. It was first developed by the German physician Samuel Hahnemann in the late 18th century, and is now used worldwide. Curious about the bark of the Venezuelan cinchona tree (which had recently been discovered by Europeans to provide an effective treatment for malaria), Hahnemann experimented on himself by drinking a tea made from the bark. Interestingly, he began to experience alternating bouts of chills, fever, and weakness, the classic symptoms of malaria itself. From this observation, he derived the law of similars, or "like cures like," which forms the basis for homeopathic theory. Simply stated, the law of similars postulates that a substance that can cause certain symptoms when given to a healthy person can cure those same symptoms in someone who is sick (see "About the law of similars").

Hahnemann spent the rest of his life extensively testing common natural substances to find out what symptoms they could cause in healthy people. This process is called "proving."

After thoroughly characterizing the effects of various substances on healthy people, Hahnemann began giving each substance as a remedy to people suffering from the specific symptoms caused by the substance. To ensure safety, he diluted the remedies repeatedly (serial dilution). Hahnemann observed excellent therapeutic results when the correct homeopathic medicine was prescribed, even when the medicine had undergone numerous serial dilutions. From this observation he derived the second fundamental principle of homeopathy—the minimum dose. This principle holds that the smallest possible amount of medicine should be used to induce the self-healing responses of the body. It is not the medicine itself that cures the illness, but rather the reaction of the body's healing mechanisms to the medicine.

Homeopathy seeks to match the symptoms produced by a particular remedy to all of the patient's symptons—physical, mental, and emotional. The goal of homeopathy is to treat the whole person, not just the illness.

Homeopathy today

Because of its safety and apparent effectiveness in comparison with other medical treatments of its day, homeopathic practice quickly spread to the rest of Europe, the United States, Central and South America, and India. According to the World Health Organization, homeopathy is the second most commonly used form of health care in the world after herbal medicine. In France, 68% of physicians consider homeopathy to be effective and 32% use it in their practices; pharmacies routinely stock homeopathic remedies.¹ In India, where there are more than 100,000 homeopathic physicians, homeopathy is practiced in the national health service.

In the US, an estimated 3,000 health professionals, including physicians, nurses, chiropractors, naturopaths, dentists, and veterinarians, use homeopathy in their practice (see "How to find and work with a homeopathic practitioner," and "To learn more about homeopathy"). Licensing for homeopathic physicians exists in only three states (Arizona, Nevada, and Connecticut), but national certification is available. Physicians can practice homeopathy in any state in which they hold a medical license. In 1990, homeopathic providers logged almost 5 million patient visits²; the percentage of adults who reported using homeopathy increased from 0.7% in 1990, to 3.4% in 1997.³ Retail sales of homeopathic medicines increased from $100 million in 1988, to $250 million in 1996.

Homeopathy and herbs—What's the difference?

Like herbs, homeopathic products are typically derived from natural sources and are commonly available without a prescription in US grocery stores, pharmacies, health food stores, and over the World Wide Web. Like herbs, homeopathic remedies are generally inexpensive—they are available in bottles of 100 tablets for $5 to $10 in the US.

There are also important differences between herbs and homeopathic remedies: namely, their sources, preparation, regulation, presumed mechanism of action, and safety. Homeopathic preparations may be derived from minerals or animals as well as plants. They are typically far more dilute than herbal remedies. Homeopathic remedies are prepared by a process of serial dilution and succussion (shaking); their potency is defined by the number of times the source material is diluted in a water or alcohol solution. For example, a 30C potency is a remedy that has been diluted by a ratio of 1:100 (one part source material to 100 parts water or alcohol) thirty successive times. This is far more dilute than any herbal product. In fact, such a homeopathic remedy may no longer contain a single molecule of the source material.

Herbal products and homeopathic remedies also differ in the way the federal government regulates them. Homeopathic medicines are prepared according to standardized methods, as specified by the Homeopathic Pharmacopoeia of the United States (HPUS),⁴ which was established by Congress as part of the Food, Drug, and Cosmetics Act of 1939. The HPUS works with the Food and Drug Administration (FDA) to set standards for good laboratory practices and to assure quality and uncontaminated production of homeopathic medicines. This means that, unlike herbal products, homeopathic medicines from different manufacturers contain the same proportion of ingredients and have been prepared exactly the same way.

Because homeopathic preparations are highly dilute, they are generally regarded as very safe. A systematic review of the literature on homeopathic medications concluded that side effects are extremely rare.⁵ The literature does describe a condition known as an "aggravation of symptoms," in which 10% to 20% of patients experience a worsening of symptoms within minutes to hours after taking a homeopathic medicine.⁶ Aggravation generally lasts no more than a few hours, however, and is usually followed by amelioration of symptoms. Whereas numerous reports describe herbal toxicity caused by product contamination with heavy metals, pesticides, and pharmaceuticals, we were able to find only one report of contamination of a homeopathic product (with a heavy metal), and that report concerned a remedy prepared in Spain.⁷

As with other CAM therapies that are used in place of, rather than in conjunction with, mainstream medicine, the biggest danger associated with homeopathy is that it will be used in situations where more aggressive medical therapy is indicated. This pitfall can be avoided by making sure that the homeopathic provider has adequate training in recognizing serious medical conditions, knows his or her limitations, and communicates well with physicians.

How can homeopathy work?

Homeopathy is one of the most controversial CAM therapies because the remedies are highly diluted. Many critics claim that because of the extreme dilution, any positive clinical results must result from the placebo effect.⁸ However, a recent meta-analysis of 89 blinded, placebo-controlled clinical trials of homeopathic remedies found a combined odds ratio of 2.45 (95% confidence interval, 2.05, 2.93) in favor of homeopathy, and concluded that the effects cannot be explained entirely by the placebo effect.⁹ How can this be true?

Although a definitive explanation of the mechanism of action of highly diluted homeopathic substances does not exist at present, several theories have been proposed. The most widely held is the "memory of water" theory, which postulates that in the process of serial dilution and succussion, the structure of the water molecules of the solvent are altered.^10,11

How is homeopathy used in children?

Homeopathy is used to treat many common acute and chronic pediatric problems, including asthma, allergies, colic, croup, eczema, behavioral disorders, otitis media, and diarrhea. Treatment by a homeopathic professional involves an extensive interview and evaluation that takes into account many things about the child, including physical health problems, family history, sleep patterns, food preferences, temperament, and behavioral patterns. Because homeopathic medicines are so dilute, they are extremely safe for children. Most remedies are administered orally on sucrose or lactose pellets that are sweet tasting and dissolve on the tongue. Even patients hospitalized in the ICU can safely receive homeopathic medicines (to reduce pain or nausea or enhance recovery from trauma, for example).

Acute otitis media (AOM). The use of homeopathy to treat AOM is based on 100 years of clinical experience. A 1992 survey of medical doctors who used homeopathy found that otitis media was the third most frequently treated illness (after asthma and depression).¹² Until recently, however, no published studies evaluating these claims existed. Since 1996, three studies of the effectiveness of homeopathic treatments for acute otitis media in children have been published.^13-15

The first study, by a group of German researchers, was a prospective cohort study comparing conventional treatment of AOM with homeopathic treatment.¹³ The researchers compared treatment outcomes for 103 children between 1 and 11 years of age who were treated with individualized homeopathic medicines and 28 similar children who were treated with decongestant nose drops, antibiotics, secretolytics, or antipyretics. Pain lasted an average of two days in the group receiving homeopathy compared with three days in the group receiving conventional medications. Children treated with homeopathy also had fewer relapses within one year (29.3%) than children who received conventional treatment (43.5%). No adverse effects were reported in either group. The study was not randomized or blinded, and the number of participants in the two treatment groups were not balanced.

Barnett reported on a series of 24 children from 8 to 77 months of age who were treated by two Boston-area physicians who regularly use homeopathy as the primary therapy for AOM.¹⁴ Rigorous diagnostic criteria for AOM, including pneumatic otoscopy, tympanometry, and acoustic reflectometry, were used. Patients were treated (in nonblinded fashion) with homeopathic single medicines, which were changed during the study period as clinically indicated. Follow-up telephone calls were made on the first, second, and third days after diagnosis, and patients were seen in the office at two and four weeks. By the end of one month, two patients (8%) were classifed as treatment failures—one on day 13 and the other on day 28— and given antibiotics. No adverse effects were reported. This study traces the natural history of AOM treated with homeopathy but, without a placebo group, it is difficult to know if the children improved because of the homeopathic treatment or recovered spontaneously.

A randomized, double-blind, placebo-controlled pilot study in Seattle, Wash., enrolled 75 children between 18 months and 6 years of age with middle ear effusion and ear pain or fever.¹⁵ Children received either an individualized homeopathic medicine or a placebo. Treatment failure was defined as any ear pain or oral temperature higher than 38° C any time after the first 48 hours of treatment or severe ear pain or a fever of 39° C or higher after 24 hours. Parents also kept a daily symptom diary. The children who received homeopathic treatment showed a statistically significant decrease in symptoms after 24 hours compared with placebo-treated children (P <.05). The prevalence of treatment failures five days after enrollment was 19.4% in the homeopathy group compared with 30.8% in the placebo group, but this difference was not statistically significant. Based on the treatment failure rates at five days, sample size calculations found that 242 children in each of two treatment groups would be needed for significant results. Larger studies are needed to assess more precisely the effects of homeopathic vs. placebo treatment in children with AOM.

Because 70% to 90% of all episodes of AOM resolve spontaneously within 48 to 72 hours and because of the widespread prevalence of antibiotic-resistant bacteria, many clinicians have developed a selective approach to treating AOM. That is, a growing number do not recommend antibiotic treatment for immunocompetent children who are only mildly symptomatic or during the first 36 to 48 hours. Homeopathy could be considered an adjunctive therapy for relief of symptoms in these situations.

A homeopathic practitioner might recommend any of dozens of remedies for a specific patient, but just a few remedies are used often to treat AOM (Table 1; see also "Case history: Homeopathy for acute otitis media"). Homeopathic combination medicines, such as Hyland's Earache, combine several of these commonly indicated remedies for ear infections into one tablet. Parents who use homeopathy to treat AOM in their children on their own should be encouraged to seek medical care if the child develops a significant fever, pain persists for more than 24 hours, or any other worrisome symptom appears.

TABLE 1
Common homeopathic remedies for acute otitis media

Acute childhood diarrhea. Homeopathy may reduce the number of stools and duration of acute diarrhea when used with standard oral rehydration therapy. A randomized, double-blind clinical trial comparing homeopathic therapy to placebo for the treatment of acute childhood diarrhea was carried out in Nicaragua in 1991.¹⁶ Subjects included 81 children 6 months to 5 years of age. Daily follow-up was done for five days. All children received standard oral rehydration therapy. Compared with the placebo group, the homeopathic treatment group showed a statistically significant (P <.05) decrease in the duration of diarrhea. The number of stools per day in the treatment group also decreased significantly after 72 hours of treatment. One or more agents considered to cause acute childhood diarrhea (enteropathogenic Escherichia coli, rotavirus, Entamoeba histolytica, and Giardia lamblia) were detected in 59% of the children.

In a similar investigation in Nepal, in 1994,¹⁷ microbes considered to cause acute diarrhea (enteropathogenic E coli, Camplyobacter, Salmonella, Shigella, rotavirus, Cyclospora, Cryptosporidium, and G lamblia) were detected in 58% of children. The mean number of stools per day over the entire five-day treatment period was 3.1 for the homeopathic treatment group and 4.5 for the placebo group (P = .02). The duration of diarrhea was 3.5 days in the treatment group and 4.2 days in the placebo group (P = .06). These results are consistent with the Nicaraguan study, suggesting that individualized homeopathic therapy may decrease the duration and number of stools in children with acute childhood diarrhea.

An interesting finding of these two studies was that just five different homeopathic medications were prescribed in 80% of the subjects. Table 2 lists the remedies and their indications.

TABLE 2
Common homeopathic remedies for acute diarrhea

Available, safe, promising

Homeopathy is widely used worldwide and readily available to growing numbers of interested families in the US. Given its safety record, we support the decision of patients who are interested in pursuing homeopathy as a complementary or adjunctive therapy. While acknowledging the limitations of current scientific knowledge regarding its effectiveness, we are optimistic about the value of the individualized approach to treatment and the promising results of the randomized, controlled trials conducted so far.

REFERENCES

1. Jonas W, Levin JS: Essentials of Complementary and Alternative Medicine. Philadelphia, Lippincott, Williams, Wilkins, 1999

2. Eisenberg DM, Kessler RC, Foster C, et al: Unconventional medicine in the United States. Prevalence, costs, and patterns of use. N Engl J Med 1993;328(4): 246

3. Eisenberg DM, Davis RB, Ettner SL, et al: Trends in alternative medicine use in the United States, 1990–1997: Results of a follow-up national survey. JAMA 1998; 280(18):1569

4. Homeopathic Pharmacopoeia of the United States (HPUS). Washington, D.C., The Homeopathic Pharmacopoeia Convention of the United States, 1988

5. Dantas F, Rampes H: Do homeopathic medicines provoke adverse effects? A systematic review. Br Homeopath J 2000;89(Supple1):S35

6. Jonas W, Jacobs J: Healing with Homeopathy: The Complete Guide. New York, Warner Books, 1996

7. Audicana M, Bernedo N, Gonzalez I, et al: An unusual case of baboon syndrome due to mercury present in a homeopathic medicine. Contact Dermatitis 2001; 45(3):185

8. Sampson W, London W: Analysis of homeopathic treatment of childhood diarrhea. Pediatrics 1995; 96(5 Pt 1):961

9. Linde K, Melchart D: Randomized controlled trials of individualized homeopathy: A state-of-the-art review. J Altern Complement Med 1998;4(4):371

10. Schwartz GE, Russek LG: Dynamical energy systems and modern physics: Fostering the science and spirit of complementary and alternative medicine. Altern Ther Health Med 1997;3(3):46

11. Jerman I, Berden M, Skarja M: Instrumental measurements of different homeopathic dilutions of potassium iodide in water. Acupunct Electrother Res 1999;24(1):29

12. Jacobs J, Chapman EH, Crothers D: Patient characteristics and practice patterns of physicians using homeopathy. Arch Fam Med 1998;7(6):537

13. Friese KH, Kruse S, Ludtke R, et al: The homoeopathic treatment of otitis media in children—Comparisons with conventional therapy. Int J Clin Pharmacol Ther 1997; 35(7):296

14. Barnett ED, Levatin JL, Chapman EH, et al: Challenges of evaluating homeopathic treatment of acute otitis media. Pediatr Infect Dis J 2000;19(4):273

15. Jacobs J, Springer DA, Crothers D: Homeopathic treatment of acute otitis media in children: A preliminary randomized placebo-controlled trial. Pediatr Infect Dis J 2001;20(2):177

16. Jacobs J, Jimenez LM, Gloyd SS, et al: Treatment of acute childhood diarrhea with homeopathic medicine: A randomized clinical trial in Nicaragua. Pediatrics 1994; 93(5):719

17. Jacobs J, Jimenez LM, Malthouse S, et al: Homeopathic treatment of acute childhood diarrhea: Results from a clinical trial in Nepal. J Altern Complement Med 2000;6(2):131

DR. KEMPER is Caryl Guth Chair in Holistic and Integrative Medicine and professor of pediatrics, Wake Forest University School of Medicine, Winston-Salem, N.C.

DR. JACOBS is clinical assistant professor of epidemiology, University of Washington School of Public Health and Community Medicine, Seattle, Wash.

The authors have nothing to disclose in regard to affiliations with, or financial interests in, any organization that may have an interest in any part of this article.

This article was supported in part by grant AT00538 from NIH National Center for Complementary and Alternative Medicine (NCCAM). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of NCCAM.

About the law of similars

The law of similars, or "like cures like," holds that remedies that produce symptoms in healthy persons can cure patients suffering from these symptoms.

Examples:

• Red onions (Allium cepa), which cause red, watery eyes and nose in many healthy people, can be used to treat patients who have symptoms of the common cold or allergies (red, watery eyes and clear rhinorrhea).

• Ipecac (Ipecacu huana), which induces vomiting in healthy people, can be used to treat patients suffering from nausea and vomiting.

How to find and work with a homeopathic practitioner

Pediatricians who want to work with homeopathic clinicians should be familiar with local providers, Web resources, the basic homeopathic process, common remedies, expected outcomes, and side effects of treatment. Homeopaths welcome referrals from physicians, and usually are more than happy to develop a respectful working relationship. Physicians should take the time to speak to and visit the office of any practitioner to whom they will be referring patients so that they can better inform patients about what to expect. Before referring, it is useful to know:

• What are your state's requirements for the practice of homeopathy?

• Has the homeopath graduated from an accredited school or training program?

• Has he or she passed a national certification exam? There are three separate certification exams: doctor of homeotherapeutics (DHt), for MDs and DOs only; diplomate of the Homeopathic Academy of Naturopathic Physicians (DHANP), for naturopaths only; and certificate in classical homeopathy (CCH), for anyone with or without a license to practice medicine.

• Has the homeopath had special training in pediatric homeopathy? If yes, what kind of training?

• How long has the homeopath been in practice, and how many pediatric patients does he or she see in a typical week? (We usually recommend a minimum of 12 months of experience, with at least three pediatric visits per week.)

• What are the homeopath's usual fees? Does he or she accept insurance? If so, which plans? Does he or she have a sliding fee scale?

• Does the homeopath carry malpractice insurance? Has he or she ever been sued for malpractice? Has he or she ever lost privileges or been forced to leave a practice or group?

• How many continuing education credits has the homeopath earned in the past three years?

• Is the homeopath a member of any local, state, or national professional groups?

• Does the homeopath recommend or sell any herbal products through the office? (If so, how certain is he or she of the purity and lack of contamination of these products?)

• What are the homeopath's referral patterns? Does he or she refer to acupuncturists, chiropractors, massage therapists, psychologists, naturopaths, or other health-care providers? Does he or she work with clergy, schools, coaches, or other professionals or institutions?

• How many patients does the homeopath see in an hour? How long is an initial office visit? (More than three patients an hour and initial visits shorter than 45 minutes raise questions about thoroughness and attention to detail and the unique needs of children.)

• How often does the homeopath recommend seeing a new patient, and what is his or her end point?

It is important for pediatricians to communicate their specific goals and objectives for their patients and to specify how often and under what circumstances they want to get status reports from the homeopath. The clearer you can be about how you want the referral relationship handled, the better the homeopath will be able respond.

To learn more about homeopathy

Books

Healing with Homeopathy, by Wayne B. Jonas and Jennifer Jacobs (New York, Warner Books, 1996)

Homeopathy: The Principles and Practice of Treatment, by Andrew Lockie and Nicola Geddes (London, Dorling Kindersley Limited, 1995)

Classical Homeopathy, by Michael Carlston (New York, Churchill Livingstone, 2003)

Professional organizations

National Center for Homeopathy, 801 N. Fairfax, Suite 306, Alexandria, VA 22314; telephone: 703-548-7790, Fax: 703-548-7792, www.homeopathic.org

American Institute of Homeopathy, 801 N. Fairfax, Suite 306, Alexandria, VA 22314; telephone: 703-246-9501, Fax: 703-273-1235, www.homeopathyusa.org

Web sites

www.homeopathic.comBooks and tapes on homeopathy

www.homeopathic.org
National Center for Homeopathy. Public membership organization, monthly newsletter, annual conference, homeopathic training opportunities

www.homeopathyusa.org
American Institute of Homeopathy. Professional medical organization, professional journal, quarterly newsletter, annual scientific conferences

Case history: Homeopathy for acute otitis media

Nate was brought to my office at 22 months of age with a history of recurrent ear infections since he was 7 months old. He had received repeated courses of antibiotics, which were no longer helping. He had a persistent middle ear effusion and developed an acute ear infection with each episode of upper respiratory infection (URI). To avoid surgery for tympanostomy tubes, his mother decided to try homeopathy.

Nate was a chubby child who had a chronic thick yellow discharge from his nose. His mother described him as stubborn and given to frequent temper tantrums, during which he would fall to the floor kicking and screaming. He had a good appetite, with cravings for sweets, salt, and eggs. He perspired easily, especially on the occipital area of the head while sleeping. He was friendly and open with other children, but was afraid of dogs and did not like to climb to high places.

Nate's physical, mental, and emotional symptoms fit the picture for the homeopathic remedy Calcarea carbonica (calcium carbonate). He was given one dose in the 200C potency (a 10^-400 dilution). Two months later, his mother reported that he had had one URI, which passed without symptoms of an ear infection. She also said that Nate's temper had improved and he was sleeping better at night. Over the next two years, Nate had one recurrence of acute otitis media, which resolved quickly with homeopathic treatment. He did not receive any antibiotics during this time. He is now 7 years old and doing fine.

Jennifer Jacobs, MD, MPH

 

Kathi Kemper, Jennifer Jacobs. Homeopathy in pediatrics--no harm likely, but how much good?. Contemporary Pediatrics May 2003;20:97.