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huddering at the thought of last year's onslaught of colds and flu, now is the time when Canadian parents start looking for ways to keep their children well during the winter.

Many of them are asking their family doctors or pediatricians about Echinacea.

"'What brand should we buy?' 'When should we use it?' and 'How much should we give?' These are typical questions I hear," says Dr. Sunita Vohra, pediatrician and director of the University of Alberta's Complementary and Alternative Research and Education (CARE) program in pediatrics. For more information, see CARE-ing in Alberta.

But wellness and prevention aren't the only areas where questions about complementary and alternative therapies and children arise, she adds. Parents concerned about seriously ill, hospitalized children are also interested in these approaches, particularly natural health products, or NHPs. "They hear about different NHPs from their friends and family, and they read about them on the Internet," says Dr. Vohra. "Parents often feel quite confused. They get lots of conflicting information. Yet, they want to try something, because they so want to improve their child's wellbeing."

			Health Canada's perspective
			Effective communications and good research are essential to ensuring Canadians can make informed choices about using natural health products, according to Mr. Michael J. Smith, a pharmacist and naturopathic practitioner who serves as a senior advisor to Health Canada's Natural Health Products Directorate (NHPD). "The best way to do this," Mr. Smith says, "is in partnership with members of the community." In keeping with this view, NHPD held extensive consultation with Canadians in the process of formulating the new Natural Health Product regulations. "The aim of both the regulations and Health Canada's Natural Health Products Research Program is to assist consumers, including parents, in making responsible choices about including NHPs as a health care option." To access consumer-oriented FAQs about Health Canada's NHP regulations, see http://www.hc-sc.gc.ca/dhp-mps/prodnatur/faq/question_consum-consom_e.html.

Whether the issue is cold prevention or battling infection in a young oncology patient on multiple medications, the absence of perfect information makes informed decision-making complicated. Dr. Vohra and others say research looking at the use of complementary and alternative health care (CAHC) in children is in its infancy, and stress that open communication and safe use are key considerations for parents interested in using CAHC for their children.

"There aren't any easy or simplistic answers," observes Dr. Vohra. This leads to what she describes as "a dance" between parents and doctors. Parents arrive with sheaves of information they've downloaded from the Web, and ideally, the doctor responds by reviewing what is known, and making a recommendation based on an analysis of the potential risks and benefits involved.

Many parents whose children use CAHC aren't engaging in the dance described by Dr. Vohra. Based on statistics compiled from multiple studies, she estimates that up to 70 percent of children with serious, chronic, or recurring illness are using CAHC. Research also indicates that many - approximately half of those children's parents - don't say a word about it to their children's doctors. As a result, parents are often integrating complementary and conventional therapies and products on their own, starting from their search for information, through negotiating the demands that special diets and health practices place on a family.

"Parents don't always disclose for good reason," says Gwen Burrows, director of the Sick Kids Foundation's National Grants Program which makes grants across Canada in the area of child health. The Foundation, associated with Sick Kids Hospital in Toronto, has taken a leading role in funding and facilitating pediatric research on CAHC. "Often, doctors and nurses simply don't know what to say when parents ask questions about complementary and alternative therapies," says Ms. Burrows, "especially in relation to children with long-term or serious health conditions."

Parents also self-censor, knowing they may be met with a skeptical or discouraging attitude. Ms. Burrows acknowledges that it is likely that among staff at Sick Kids Hospital, there are some doctors who are skeptical of any complementary or alternative therapies and an equal number who are interested in exploring what they perceive as the field's potential.

The resulting communication gap is worrisome, according to both Ms. Burrows and Dr. Vohra, because multiple factors mean that children respond quite differently to treatments - both conventional and complementary - than adults.

"Open lines of communication are crucial," Dr. Vohra says. "Find a health provider -- a family doctor or pediatrician -- and open a dialogue about your interest in complementary therapies - and ask about theirs."

"Keep your health care providers in the loop," she adds. "This is important, because too many things are falling through the cracks right now." For example, children are showing up at the hospital to have surgery, and their parents don't think it's important to mention they are taking Natural Health Products, some of which can have an anticoagulant (blood-thinning) effect. This kind of scenario can be avoided if parents and doctors are communicating well.

"People need to give a complete snapshot of what they're doing - to all the providers they see," Dr.Vohra says. "The first piece is open communication. The second is to seek quality information." She urges caution when looking at resources produced by companies interested in making a sale. "You should be a discerning, skeptical consumer."

The new Natural Health Product (NHP) regulations should help assure consumers about product quality, Dr. Vohra adds. Parents who remain interested in using NHPs with younger children should seek expert guidance. The same care should be used regarding CAHC practices, such as acupuncture. "You have to ask questions about their pediatric experience and education."

Pediatric knowledge and experience are important, because there are significantly different issues for children's health than for adult health, Ms. Burrows says. Issues that arise in pediatric health research - in both CAHC and conventional medicine - should also concern parents. "Appropriate dosages are still rarely established for children for NHPs," says Ms. Burrows. "In part, this is because children are more difficult to study. Often the numbers of children affected by a particular illness is smaller than an adult population, and the ethical issues around studying children can also be more complex.

"Children's bodies are still growing and developing," Ms. Burrows adds, "so they may be more vulnerable to dosage errors, or adverse effects of drug/NHP interactions. There are also concerns about potential long-term effects of exposure to NHPs - or pharmaceuticals - during times of children's peak growth and development.

"If children have an illness or disability," says Ms. Burrows, "they need to receive developmentally appropriate care, whether conventional, complementary or alternative. Newborns are particularly vulnerable to certain illnesses."

Re-emphasizing the importance of communication, she continues, "it's also important to establish how much complementary and alternative practitioners know about child- specific issues, and whether they know when it's appropriate to refer a patient to a doctor."

Quality information about pediatrics and complementary and alternative health is still scarce, Dr. Vohra acknowledges. But Sick Kids Foundation and CARE are taking steps to improve the situation. In September, the CARE program launched PedCAM a new network funded by the Sick Kids Foundation. Primarily intended to link researchers and educators interested in pediatrics and complementary and alternative health care, PedCAM also includes people, groups and agencies interested in keeping up-to-date in pediatric CAHC initiatives and opportunities. PedCAM's launch will be officially celebrated in December, when the Foundation holds a forum showcasing pediatric CAHC research that the foundation has funded over the past two years. (See related story, CAHC Pediatric Research - Moving Forward.)

There are still many more questions than definitive answers in this field, but Dr.Vohra tells parents who are interested in complementary and alternative health care for their children that recent developments, including the emergence of a program such as CARE means this is a time to "feel encouraged."

"Patients are using CAHC, and science is trying to catch up," she adds. "Ultimately, our goal is the same as the parents' is - to improve the health of children."

HolisticKids.org - a US Web-based resource created in collaboration between Children's Hospital Boston, and other centres of health research in Massachusetts as a tool for educating pediatric medical residents. Its range of high quality resources is limited at this time, but under development.

Motherisk - A Web based resource for evidence-based information about the safety or risk of drugs, chemicals and disease during pregnancy and lactation. Motherisk is produced through a program at the Hospital for Sick Children (Sick Kids) in Toronto. The site includes studies and information on several NHPs, including Folic acid, and Echinacea.

1. Davis, M. P. and Darden, P. M. Use of complementary and alternative medicine by children in the United States. Archives 157[4], 393-6. of Pediatrics & Adolescent Medicine. 2003 Apr.
   
   Ernst, E. Prevalence of complementary/alternative medicine for children: a systematic review.[see comment]. [Review] [28 refs]. European 158[1], 7-11. Journal of Pediatrics. 1999 Jan.
   
   
2. Lanski, S. L., Greenwald, M., Perkins, A., and Simon, H. K. Herbal therapy use in a pediatric emergency department population: expect the unexpected. Pediatrics 111[5 Pt 1], 981-5. 2003 May.
   
   
3. Health Canada, Health Products and Food Branch, NHP Research in Children and Youth: A Priority-Setting Conference, March 17-18, 2002, Toronto.

CARE-ing in Alberta

CAHC Pediatric Research -Moving Forward