Complementary and alternative medicine use among pediatrics in Palestine: a cross-sectional study

Complementary and alternative medicine (CAM) is a formal method of health care in many areas of the ancient world and is expected to be integrated widely into the modern medical system and become part of it [1, 2]. CAM is a group of diverse medical and health care systems, practices, and products considered outside conventional medicine or used as an alternative to the traditional ones [3, 4]. However, it is not taught in traditional medical schools and is not applied in hospitals [5].

Many types of CAM are quite diverse in different areas of the world, and they are influenced by culture, history, use, level of education, and individual interests. Countries such as China, South Korea, and Vietnam have accepted the use of complementary medicine in their health systems [5]. CAM is commonly used among adults; also it has been reported to be used among children, especially among those with a parent who uses CAM for treatment or prevention of painful, chronic, recurrent, or incurable conditions [6]. People think that CAM use has many advantages over conventional medicine; they believe that CAM is more effective, safe, has a good patient/therapy relationship, and controls treatment. Moreover, the availability, acceptability, cost-effectiveness, and expectation of low side effects of CAM may increase the challenge of health care [7, 8].

The most common reason for using CAMs among pediatrics is parents’ fear of possible adverse effects of conventional medicine use. Thus, patients in several countries tend to use CAM despite being more efficacious prescribing therapy [6, 9, 10]. Furthermore, people think that conventional medicines have more side effects, and they do not prefer to go to doctors and wait for time to get treatment [7, 8]. It is known that the influence of parents, particularly mothers, on their children on how to take CAM and other medicines is highly effective [11, 12].

In pediatrics, the use of CAM is increasing worldwide. It has been used for different chronic illnesses such as asthma, arthritis, gastrointestinal diseases, neurological or developmental disorders, cancer, and other diseases. Despite the increased use of CAM among them, only a few parents tell physicians about CAM use; others don’t tell them, which may increase side effects and interactions with conventional medicines. Therefore, the attention of CAM use among pediatrics is increased to know its impact on their lives and develop evidence-based advice about their risks and benefits [13]. Due to the significant increase of CAM use among pediatrics worldwide, including Palestine, it is highly recommended to recognize and assess the prevalence of different CAM types among children in Palestine. This emphasizes the importance of understanding their worth and helps parents know its effect on their children. To date, the evaluation of CAM has received scant attention in the research literature in Palestine, considering aspects other than the use of CAM in children [8, 14‐22]. To our knowledge, there are no available published data regarding the use of CAM in Palestinian children. Therefore, this study was performed to assess the use of different CAM types among children in Palestine, determine the main reported health problems treated with CAM among children, and evaluate parents’ main general views about CAM use. It is hoped that this research will contribute to a deeper understanding of this growing field of research by helping to prepare the strategies needed to improve the self-use of CAM. In addition, the findings can help develop educational programs to enhance parent counseling to avoid improper use of CAM and support university decision-makers to agree on the best courses to be given to medical students about CAM.

Many researchers worldwide have studied CAM use among pediatric patients, and this is the first study that focused on CAM use in pediatrics aged 6 years and below in Palestine. All parents reported the use of CAM in their children, and this result is because the current study does not focus on certain diseases, and most CAM subtypes were included in addition to the effect of culture.

The prevalence of CAM used in previous studies from Western countries conducted in Italy [25], Finland [10], and Canada [26], were 18-38, 11%, and 59-74%, respectively. In the Italian study, the most common CAM methods used were homeopathy, acupuncture, phytotherapy, traditional Chinese medicine, chiropractic, osteopathy, and anthroposophical were considered [25]. Furthermore, at a university hospital in Mexico, 45% of all parents mentioned that they used CAM with their children who suffer from hematologic problems [27].

At the Neurology Clinic at King Abdullah University Hospital, about 56% of parents who came with children with neurologic diseases such as epilepsy, cerebral palsy, and congenital brain malformations used CAM with their children [28].

The rate of CAM use in Palestine seems to be higher than that in other countries because parents often think that CAM use is more natural, safer, and less invasive than conventional medicine. Moreover, as mentioned before, our survey was comprehensive in two aspects, the first is according the reasons for CAM use which are not specific and include general health problems, and the second is that parents were asked about CAM which includes a wide range of CAM subtypes whether it is a practice like a massage or a product like a herb.

In the current study, herbal therapy is the most commonly used CAM among parents (400, 95.2%), followed by Quran reading (381, 90.7%), oil rub (364, 86.6%), and prayer (351, 83.6%). These results were consistent with the results obtained from a study conducted by Sawalha [8] among adults from the northern part of Palestine, which found that herbal therapy and prayers were the most CAM types. In addition, a study in Turkey that explored the use of CAM among Turkish children found that herbal therapy was the most common CAM used [23].

A study in Germany that was developed to assess CAM use among healthy children and children with chronic medical conditions found that homeotherapy was the most therapy used [13]. In the United Kingdom, a study found that massage, aromatherapy, and homeotherapy were the main CAM types used for healthy children and among children with chronic illness [29].

It is expected that herbs are among the most commonly used CAM because many people believe that herbs are natural and always safe and suitable for their children, but this is not necessarily true. Moreover, these herbs are almost cheap and available. In addition, prior to recorded history, plants were used to treat illness; ancient Chinese and Egyptian papyrus writings identify medicinal uses for plants as early as 3000 BC [30], so their use moves from generation to another until it reaches us.

Regarding the health problems that were treated by CAM, in the current study, digestive and respiratory health problems were the most commonly treated conditions by CAM. In addition, 86.9% of parents reported that they used CAM to make their children more comfortable. These results are consistent with a study in Saudi Arabia conducted by Ashraf et al. [31]. They found that CAM is used more often in children with gastrointestinal and respiratory tract symptoms. In the Netherlands, CAM was used mainly to treat children with headaches, chronic fatigue, and parents’ desire to make their children feel better [32]. Furthermore, in Turkey, CAM was used for children with respiratory and digestive system problems with percentages of 49 and 25%, respectively, and 59% of parents used CAM mainly to make their children more comfortable and 25% to support prescribed drugs [23].

Regarding the source of information from which the parents received information about CAM, about 96% of parents mentioned that relatives and friends were the main sources of information about CAM use. This is consistent with a previous study by (Ozturk and Karayagiz, [23] which concluded that family and friends were the primary sources of information for CAM use in pediatrics in Turkey.

In Iran, in a study that evaluated the prevalence of use of CAM in children, relatives (72%) and neighbors (50%) were the most sources of knowledge about CAM for parents [5]. However, this is with study in Italy, where physicians were the source of information about CAM and were prescribed by them [33].

Most interviewers in our study (91.5%) found that CAM was useful and 87.9% of them believed that CAM has no complications or side effects. These attitudes were similar to a study in Iran, in which only 1.3% of mothers identified that CAM might have some side effects or complications [5]. In addition, in a study to assess CAM’s use among patients attending neurology clinics in Canada, most participants thought that CAM was beneficial, with little to no harm involved [26].

The safety or effectiveness of CAM in children has not been tested, and side effects may differ from those seen in adults. Children’s metabolism and their immune, digestive, and central nervous systems are still evolving and maturing, so parents should be aware of this when using CAM with their children. In a study by Lim and colleagues [34] aimed to determine the types of adverse events associated with CAM use during the period between (2001-2003) as seen by Australian pediatricians, 46 reports of adverse events were recorded to be caused by CAM use. In a Canadian study, 7% of pediatricians and pediatric subspecialists reported seeing adverse events and 18% reported cases of delayed diagnosis or treatment due to using CAM [4].

In this study, the statistical analysis showed that parents’ age was a significant factor affecting the number of CAM used; parents who are 30 years or older use CAM in their children more than other ages. This result is consistent with a study in Iran by Fesharakinia and Abedini, [5] where parents between the age of 30-40 years use CAM in their children more than other age categories. Moreover, parents who have five children or more used more CAM subtypes than parents who have fewer children. These results may be explained as those parents have more experience and gather more knowledge and awareness during their life regarding child diseases and CAM use, and they are still practicing what was done in the past as people before depend more on CAM therapy. Additionally, parents who have many children found it more cost-effective to use CAM than visiting doctors.

In addition, our study found that parents living in the refugee camp used more CAM subtypes than parents living in urban or rural areas; this result is consistent with a previous study conducted by Ali-Shtayeh et al., [14] that found the use of CAM differed significantly between residents of refugee camps versus residents of urban or rural areas where camps residents used more CAM than others. This can be explained that families living in camps may be poorer. Thus, they depend mainly on CAM rather than on medications.

In addition to that, CAM use was higher in those with health insurance, like a study conducted in a tertiary children’s hospitals in Australia where CAM use was higher in those with health insurance [34].

Furthermore, half of the parents said they make physicians or nurses aware of their CAM use. Such a study in Canada explored the use of CAM among children attending neurology clinics, where 57% discussed using CAM with their physician [26]. While in Australia and Newzealand, 63 and 77% of parents reported that CAM use had not been discussed with their treating doctor [34, 35].

It is necessary to tell healthcare professionals about CAM use in the pediatric patient, and physicians should be attentive when prescribing medication and ask parents if they use CAM. This is important because concurrent use of CAM and conventional medications are widespread and carry a potential risk to patients who may be susceptible to drug interactions.

Complementary and alternative medicine is used commonly in pediatric patients in Palestine. Herbal therapy, especially “Anise” was the most common CAM used. Regarding the diseases treated with CAM, digestive system problems were the most common problems, and making the child more comfortable is the most common reason for CAM use. On the other hand, most parents felt that CAM use was helpful, with few or no associated adverse effects, so it is highly recommended to aware people about the proper use of CAM. The most common source of information for CAM among the study parents was information from relatives and friends, and nearly half of the parents did not tell the physician about CAM use. The results of this research have a variety of substantial consequences for future practice, including 1) complementary and alternative medicine use in the community must be improved through better parent and physician education of appropriate CAM use; 2) It is recommended for physicians to be aware of patients using CAM and ask about CAM use while taking a patient history, and 3) Pharmacists and clinical pharmacists have a law of consciousness to raise the risk of encounters with conventional medicines.