The CAM network – Challenges and opportunities

Over the past two decades, there has been an increase in both interest in and use of complementary and alternative medicine (CAM) among patients in the developed world. This has been best documented among adult patients, but it is increasingly clear that CAM is more widely used by families for the treatment of children, especially children with chronic diseases. The frequency of CAM use among children with some chronic disorders approaches 70%. The increase in interest in CAM is related to a number of factors: cultural belief in the use of traditional medicines, the assumption that natural therapies are more likely to be safe, and the unfortunate fact that our ability to control many chronic diseases and the adverse effects of conventional therapy is less than optimal. This presents a problem for the child health care practitioner. First, many parents are reluctant to disclose to the practitioner that they are using CAM for fear of damaging the doctor-patient relationship or of being labelled a CAM user. Second, even when families do disclose the use of CAM, the child health care worker is often faced with a paucity of reliable information on the efficacy and safety of these preparations, notably when used in combination with conventional medications. This is unfortunate for all concerned because there is increasing evidence that CAM may be more efficacious, but also less safe, than was previously believed. As an example, we now know that St John's wort is a moderately effective agent in the treatment of moderate depression. It is also known that St John's wort is a modestly effective inhibitor of CYP3A4, the isozyme of the cytochrome responsible for 50% of human drug metabolism via cytochrome P450, including the metabolism of cyclosporine, nifedipine and nelfinavir. An additional example is the fact that many therapeutic products (ranging from antibiotics to immunosuppressives) originated from natural products. Teaching about CAM in the undergraduate and postgraduate medical curriculum of most conventional practitioners ranges from scant to none. Thus, the child health care practitioner is faced with a major knowledge gap in terms of providing optimal therapy for children and their families. In this context, the development of PedCAM, a child-focused CAM Network, is a welcome development. What is the promise of such a network? First, it provides an opportunity for clinicians and researchers with an interest in CAM to interact on a regular basis with people with similar interests. This includes the opportunity to collaborate with international partners. The development of National Institutes of Health-supported research units in the United States and international groups such as the Consortium for the Globalization of Chinese Medicine suggests that there is rich potential in such collaborations. This leads to the second opportunity, which is the development of research projects to assess the safety, efficacy and optimal use of CAM to help guide practitioners to use the right therapy for the right patient. The third opportunity is the dissemination of validated evidence-based information about the appropriate use of CAM to the general community of child health care workers and families. The development of a network also raises challenges. An effective network requires professionals from diverse backgrounds, often with quite different skill sets and, possibly, quite different world views, to work in a collaborative manner that recognizes and respects these differences. One of these differences involves the generation of evidence-based approaches, which for some traditional practitioners constitutes a very different philosophy from the one with which they have been trained and practice. As well, conventional practitioners with ingrained prejudices against CAM will need to adopt a more open-minded attitude if the synergistic potential of combination approaches is to be achieved. Special challenges in evaluating CAM include the identification of the species of plants used, the purity of the products under evaluation, the difference in interventions produced by different growing conditions and variations on the part of individual practitioners, and the potential for adulteration of the interventions being studied. An additional challenge related to working with children is the general lack of knowledge with respect to therapeutics in this population, including the use of conventional medication. In addition to the challenges related to working with CAM and with children, there are the generic problems of running a network, including the need for a robust infrastructure, excellent communication, effective leadership and the need to deal with the fatigue that can affect network members once the initial enthusiasm of the network fades. Having said all of this, the potential for a CAM network is tremendous, especially if, as noted above, this can be accompanied by collaboration on initiatives to improve the understanding of the use of conventional therapies in children. The use of CAM in children is common, and for children with many chronic diseases, CAM is the norm. Understanding the potential roles of CAM and conventional therapy, including selecting the correct patients for therapy, and determining the efficacy, safety and interaction data is of critical importance to the common goal of child health practitioners, which is to provide the best treatment to the children under their care. Thus, the development of a paediatric CAM network is of interest to a number of parties, and those interested in obtaining further information are encouraged to visit the PedCAM Web site at . Dr Rieder holds the GSK-CIHR Chair in Paediatric Clinical Pharmacology at the University of Western Ontario. Dr Rieder's research is supported by the Canadian Institutes of Health Research, the Robarts Research Institute and the Children's Health Research Institute.

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