Herbs Every Pediatrician Should Know by SupremeLord

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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
                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.
  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
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
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?
Asking patients
 • By show of hands, how many
   people in this room use an
   herbal product 4 + days
   weekly to achieve a health
   goal?
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
                 Be Safe!
1. Ask all patients and document the product,
   ingredients and manufacturer in medical record
2. Herb-drug interactions can occur
3. „94 DSHEA means little consumer protection;
   marked variability in purity and potency
4. Use caution during pregnancy, lactation and
   infancy, and with other biochemical remedies
5. Opportunity costs - using herbs when another
   approach would be more cost-effective and safer
                  M Cirigliano, JAMA, 1998;280:1565-6
Herbs and Medication -
     differences
           • Processing
           • Purity
           • Potency
           • Politics/ regulation
           • PR – perceptions,
             marketing
           • Power of advertising;
             impact on peer review
    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/
http://www.fda.gov/downloads/Saf
ety/MedWatch/HowToReport/Downl
     oadForms/ucm082725.pdf
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”
        Safety Summary
• Herbs are not
  necessarily safe just
  because they‟re
  natural
• Herbs work
  biochemically
• FDA regulation
  needed to assure
  purity/potency
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?
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?
Aloe vera - History and
    Common uses
         • used by Egyptians
           (Cleopatra‟s beauty
           secret?), Greeks,
           Chinese, Ayurveda,
           S. Africa, S.
           America
         • Used for:
           – burns and skin
             irritations
           – ulcers, canker sores
           – laxative
        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?
   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
 Aloe - bottom line

• good for home treatment of minor
  wounds including burns, scrapes,
  etc.
• possibly useful for canker sores
• very safe for external use
             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 aren‟t
   allergic to any, which of the following
   “herbal remedies” is safest?
  A. Beer
  B. Whiskey
  C. Chamomile/lemon balm tea
  D. Kava kava
Chamomile
    • Mild anti-inflammatory
    • Mild sedative (stress,
      insomnia)
    • Mildly relaxes intestinal
      spasms (colic)

    • Yes, Peter Rabbit‟s
      mother was on to
      something (1 Tablespoon
      to be taken before
      bedtime - rabbit dose)
Chamomile - Biochemistry/
   Active Ingredients

        •   chamazulene
        •   alpha-bisapolol
        •   apigenin
        •   flavonoids and other
            antioxidants
 Chamomile - Scientific
      Evidence
• apigenin binds GABA receptors - like
  many sedatives
• RCT of essential oil fragrance in young
  adults: signif. calming
• Case series:10/12 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
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
Valerian - Smelly soporific
   • Galen used to treat seizures
   • 1700‟s - 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
    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 ->signif
  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
Valerian - Toxicity/Side
        Effects
• Very safe even in those who‟ve taken
  huge intentional ODs
• Mild side effects - headaches,
  restlessness
• No apparent addictive or dependent
  qualities; no interaction with EtOH
Stress, part 2
    • You like caffeine, but
      want to avoid the
      jitteriness and
      irritability. What else
      might you drink?
    • WHY?
      Green tea
• Theanine (amino acid)
• Counteracts negative effects of
  caffeine without making you
  sleepy
             Kimura K. Biol Psychiatry, 2007
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?
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
      don‟t)
Echinacea- Botany
        • Activity varies by
          species, part used,
          harvest timing,
          preparation, storage
        • MANY different
          constituents
  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
   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
Elderberry    (Sambucol)
   • used in folk medicine to treat
     influenza, colds and sinusitis
   • has antiviral activity against
     influenza and herpes simplex
   • RCT of adults with < 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
             Ginseng
• 5 Canadian studies including > 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
          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
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
Feverfew: Tanacetum
    parthenium
  • Purity and potency vary
    markedly between products;
    British > 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
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
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
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. John‟s wort a good idea?
 (Note: if he asks you, he‟s probably
 already using it. Ask about which
 brands he‟s tried and what he‟s already
 read on the internet)
St Johns Wort
   • Depression – possibly
     effective 300 mg three
     times daily
     http://nccam.nih.gov/healt
     h/stjohnswort/
   • Sunburn
   • Interferes with many other
     medicines
   • Which brands contain what
     they say they do?
   • http://www.consumerlab.c
     om/results/sjw.asp
            Resources
• Free
  – NIH NCCAM
  – *NIH MedLine Plus
  – WFUBMC - BestHealth
• Subscription, but worth it
  – Natural Medicines Comprehensive Database
  – Natural Standard
  – ConsumerLab.com
       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@aap.org or
  www.aap.org/sections/chim/
Extra Info Slides
    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
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
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
   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 (Alzheimer‟s
  prevention?)
• Absorbed better with oil and black pepper
• Safety: causes biliary contractions (avoid if
  stone history); inhibits platelet aggregation

								
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