Cora Collette Breuner, MD, MPH, on Herbs and Supplements in Children and Adolescents
In this podcast, Cora Collette Breuner, MD, MPH, speaks about the safety and efficacy of herbs and supplements in children and adolescents, including combinations that should be avoided in certain populations, adverse side effects, and questions clinicians and members of the health care team need to ask patients, parents, and guardians, as part of the health care visit. She presented on this topic at AAP 2021 National Conference and Exhibition.
- Breuner CC. Safety and Efficacy of Herbs and Supplements in Children and Adolescents. Talk presented at: American Academy of Pediatrics Virtual 2021 National Conference and Exhibition. October 8-11, 2021; Virtual. https://www.eventscribeapp.com/live/slides/view.asp?svfp=MTUwOTZ8NTMwMzQ2NjB8MTU4MTEyfDkxMDE3MHxXZWJzaXRl
- McDonagh MS, Holmes R, Hsu F. Pharmacologic treatments for sleep disorders in children: a systematic review. J Child Neurol. 2019;34(5):237-247. https://doi.org/10.1177/0883073818821030
Cora Collette Breuner, MD, MPH, is an adolescent medicine physician at Seattle Children’s Hospital and a member of the American Academy of Pediatrics Executive Council for holistic and integrative medicine. She’s also a professor of pediatrics at the University of Washington School of Medicine in Seatle, Washington.
Jessica Bard: Hello everyone, welcome to another installment of "Podcast 360," your go‑to resource for medical news and clinical updates. I'm your moderator, Jessica Bard, with Consultant360 Specialty Network.
According to the Centers for Disease Control and Prevention, 34% of children and adolescents aged 19 years or younger, used a dietary supplement in 2017 to 2018, and sales are rising during the COVID‑19 pandemic.
Dr Cora Collette Breuner is here to speak with us today about her session, Safety and Efficacy of Herbs and Supplements in Children and Adolescents, presented at AAP Virtual 2021 National Conference & Exhibition.
Dr Breuner is an adolescent medicine physician at Seattle Children's Hospital and a member of the American Academy of Pediatrics Executive Council for Holistic and Integrative Medicine.
She's also a professor of pediatrics and adolescent medicine at the University of Washington, School of Medicine in Seattle, Washington. Thank you for joining us today, Dr Breuner. Can you please give us an overview of your session?
Dr Cora Collette Breuner: Thank you so much for asking me to speak today about this. This is something I'm very passionate about because I do feel that the use of herbs and supplements is very prevalent in our children and adolescent, and young‑adult populations. We need to make sure we ask about it at each and every visit.
I also think that there's a lot of interactions between herbs, supplements, and the medications we prescribe that clinicians should know about. We also need to know the evidence in terms of efficacy for certain herbs and supplements. Some of them work, and some of them don't.
Jessica: Are herbs and supplements safe and effective in children and adolescents? Are there certain combinations that should be avoided in certain populations of children and adolescents?
Dr Breuner: There are certain herbs and supplements that are not effective, or they might be effective at a dose and then they become tolerant to this herb or supplement. Patients and families might increase the dose of the supplements, which is not evidence‑based, but what they do.
There are certain kids who are taking some prescription medications who should not be taking any herbs or supplements. In particular, those with clotting abnormalities.
If you attend my session, you'll learn a whole bunch of great stuff about the different things that might work for a patient with a specific complaint. You might learn some data about things that wouldn't work or that might even be dangerous for a child, adolescent, or young adult to take.
Jessica: I know your presentation is about an hour long or so, but can you get into a few of those things that you might talk about?
Dr Breuner: Yes. I do a lot of case‑based studies because I like to make sure that my audience has some tools to take with them.
These are cases from my practice where I have had specific patients come in with a set of complaints, and the family or caregiver wants to try something natural, even though there may not be data that shows it would work as well as something that was more conventional.
For example, I talk about a 14‑year‑old female in my practice who'd been suffering from depression during the COVID pandemic, and was feeling quite blue about friends and family. The parents wanted to try holistic herbs and supplements, such as St. John's wort, tryptophan, and fish oil.
We did a deep dive into looking at this for their child. I did show them some of the data in terms of efficacy or lack of efficacy for specific herbs and supplements for that particular complaint in their child.
The thing that's really important is that many people go to search engines, such as Google or Bing, and they try to look up different things that might work in terms of natural remedies. It's hard for somebody that isn't a health care clinician to actually unpack some of the studies.
What I like to do in this presentation is help the clinician do this with their patients. Help them read these papers in real time, if they come to my session they'll learn this, and be able to mindfully and thoroughly give some kind of best-practice recommendation for their patient or the parent or caregiver.
Jessica: We talked about some dietary herbs and supplements interacting with a child's medication. Do any dietary herbs and supplements have unwanted side effects of their own, individually?
Dr Breuner: Yes. Many, many herbs and supplements actually work through a pathway that interferes with the coagulation cascade, which is the clotting system.
For example, if you have a child that is undergoing chemotherapy for cancer, which will interfere with the bone marrow, it has bone marrow suppression, so they have low platelets and are anemic from the medication, the chemotherapy.
Parents, especially when the kid has a medically complex chronic illness, are much more likely to use natural 90% of families with a child with a chronic medical condition will use an herb or supplement.
If you are giving your child something that interferes with platelet aggregation or with clotting, then they're more likely to bleed. We'll talk about this in detail in the session I give, why it's so imperative to go over this with families in a non‑judgmental way when you're taking your history, because they don't actually know.
Honestly, the industry is not regulated in a way that they would say, for example, St. John's wort, it doesn't say on the bottle, "will interfere with platelet aggregation." It just says, "Please consult your physician if there's other medications your child is taking," or patient is taking, but it does.
In the emergency rooms, for example, if a child will come in and be oozing after a car accident, have blood loss that's excessive and no one can figure out why they can't get this patient to stop bleeding, it's maybe because they're taking a herb or supplement and hadn't disclosed it to the team in the emergency room.
That's why it's important. Natural doesn't necessarily mean that it's safe. In fact, natural might have some unsafe qualities in these products. I don't mean to malign the whole industry. We'll talk a lot about reputable products and reputable companies.
I don't want the people to come to the session to come out and say, "All of it's terrible, and I'm not using any of this in my practice." I'm going to tell all my patients, no, that absolutely is not what I want my clinicians and those who attend this session to come out of my session.
I want them to be open‑minded and be aware that their patients are using these herbs and supplements frequently, and that they with due diligence need to partner with their families, caregivers, and patients, to make sure that whatever they're taking works for what they're trying to take it. That it's safe and doesn't interact with anything else they're taking.
Jessica: You touched on this a little bit of about taking a patient's history. What types of questions do clinicians and members of the health care team as a whole need to ask patients, parents, and guardians as part of that health care visit?
Dr Breuner: Thank you, Jessica, for asking that question because that is a huge one. We do know from data and from looking at how we take histories as clinicians is that we rely on those who room the patients ‑‑ medical assistants or nurses, or whoever puts the patient in the room ‑‑ to take a medication history.
If that person doesn't ask the patient or caregiver, family, what else are they taking, then we may never get at supplements. Because even though it's in the history and it's on the chart in the electronic medical record to ask that, it's not necessarily something that all people do just because they don't.
The patient or the caregiver might think, "Well, if they didn't ask me about it, I guess it's OK." Which is not true. It just means they didn't do it. That's why I always tell those who are attending the session, make sure you do like a repeat back with the patient or family or caregiver in the room.
You review and you say, "Your kid is using an inhaler for asthma or is taking a multivitamin. Anything else? Are there any other herbs or supplements that aren't on in the chart that we need to go over today?"
Not judgmental, not in a way that's with an eye roll and I don't know. No way do I want people to be asking people that, that way, because that really means they're going to keep doing it. They're just not going to tell you about it anymore because you disagree with them or you don't think it works, whatever.
It's not a place where we should have judgment. In fact, we should be much more open and embrace that our patients' families or caregivers are very interested in their child's health and they really want to do what's best for their child.
That's how I approach this." I understand that you really want to try a 10‑mg dose of melatonin in your kid because the 3‑mg dose doesn't work anymore. I understand that that's really hard to get your 3‑year‑old to get to sleep."
"However, that's too high. That's too much melatonin. There's no studies that show efficacy. Let's try some other techniques. Let's try to drop this dose back to what's been studied, which is 0.5 to 1-mg up to 3-mg." That's it. In a 3‑year‑old I mean that so...
I hear this all the time so that people understand that families want their caregiver team to partner with them and answer their questions. They don't want to hurt their kids. No one wants to do that. That's not the point.
The point is that they want to make their kid better in a safe and efficacious way as possible, and our job is to support that.
Jessica: You mentioned melatonin just now, do you want to talk a little bit about melatonin and multivitamins? I know that those are some big‑ticket items that people will be asking you about. That's part of your presentation. Talk to us about melatonin and multivitamin, and are those safe for children and adolescence?
Dr Breuner: Melatonin's been around for quite a long time. One of the things that's interesting, melatonin is not an herb. It's a supplement, in fact, it's a hormone. It originally was studied in those folks who were traveling from New York to Paris.
I wish I could have been part of that study, wouldn't that have been lovely because they gave it to the people in the study and compared to those who were not in the study to see how quickly they could reboot into the time zone 5 hours earlier.
Jessica: Sign me up for that one.
Dr Breuner: What the heck, I would have loved to be a part of that study and what does it mean to be in the time zone? I don't actually know what they actually asked in terms of the variables. We were able to sit and stare at the Eiffel Tower and not fall asleep. I don't know.
Anyway, that was the study that started this whole thing in the '80s and then, honestly they started to unpack it a little bit more and realized, it does work for a lot things besides jet lag, and it does work for those who sleep latency which means it's hard to fall asleep.
It doesn't work very well for night waking's, which is when you wake up multiple times throughout the night, and have a hard time falling back to sleep.
It's much more for sleep latency, and it's important to understand that it needs to be given 3 or 4 hours before someone is trying to get to sleep, because all these herbs and supplements are not regulated at all by the FDA.
The FDA wants to know if there's an adverse effect. You could call the FDA adverse effect line or a poison control in your state and report that, but there's no monitoring of these products when in terms of whether the product is efficiently and effectively batched in the same vial and it's got an expiration date, etc.
The studies that have been done in children for sleep latency are very much using a very much lower dose than what people think is the right dose. It's 0.5-mg to 1-mg are the actual gold standard studies that were done in children, 3 years and up.
A couple of studies have come out. I'll talk about those more in this session for kids older, and especially with kids with autism spectrum disorder, who have difficulties falling asleep. Those studies show that the dose can go up to 6-mg at night, but if you really unpack these studies and they were really well done.
They're very good studies. It is that in addition to using the melatonin, they're also doing a lot of sleep hygiene work, like they're also doing a lot of work on making sure all screens are off. Making sure that there's not a lot of reinforcement with a child getting up out of bed and not going into the parents' bed.
There's a lot of "and" in these studies, which is wonderful because none of us want these kids on something like melatonin forever because it's a hormone and there's a couple of theoretical issues, not substantiated it robustly in the literature, to be honest with you, on melatonin and its effect on the hypothalamic‑pituitary‑axis, i.e. menstrual period in girls.
Does it delay them? Does it cause early onset puberty? It's not like Echinacea which is a plant. Melatonin is a supplement that's made actually in the laboratory now, but it originally is from the pineal gland of cows, so that's how the original studies, which is called bovine, or cow pineal gland.
It's fascinating. It's not unstudied, but it is something that if you're going to recommend it, I always recommend it for 6 to 7 weeks, maybe up to 3 months, and you have to give a wash out period, so that you're not building tolerance.
You're actually aware that you are going to have to take a break on it because the kids develop and adults too actually develop a tolerance to it. Then they keep thinking, "Oh, let's take more," but that's not been studied and it's probably not a good idea.
Jessica: What would you say are the key takeaways from your presentation? If someone is leaving your presentation, what do you want them to take home?
Dr Breuner: The first thing I want them to take home is come hear me talk about other stuff [laughs] because I do a lot of other stuff for the academy, and integrative holistic medicine, as do my colleagues on the section, on integrative medicine, but other key takeaways, is that make sure that the clinician is asking about herbs and supplements in every single health care visit.
Not just at the well child visit, not just at the sports physical visit, but every one because it just takes an extra couple of minutes, but you could actually really do a lot of health education and safety.
If you asked these questions and you found out that these parents are giving these kids herbs or supplements that would interfere with what you're prescribing.
There's a demographic that people think is pretty classic for herbs and supplements, but the research has shown that across all ethnicities, all socio‑economic groups, across all cultures, across all minoritized populations. There is a large population of kids and families who use herbs and supplements.
Again, at every health care visit, these questions need to be asked in a non‑judgmental fashion with the understanding that there's going to be some discussion about efficacy and safety.
The second take‑home point that's very important is to make sure that the person attending the session leaves with resources to look up safety and efficacy data for herbs and supplements. There's a number of really reputable search engine medical groups that are looking at our herbs and supplements.
The most important one is called Natural Medicine Database, which I encourage all the attendees to make sure their hospital library or their clinician groups have nimbly right next to up to date in terms of looking up information on herbs and supplements.
I want to make sure that those who come to this session leave with lots of answers for questions that they have, about how to ask these questions in a mindful and respectful way, and how to help their patients and families and caregivers come out of their visits with data and information to make sure their kids are happy and healthy.
Jessica: Thank you so much for your time today, is there anything else that you'd like to add that we missed?
Dr Breuner: Yes. The last thing I would like people to know is that there is a very powerful group of us, within the American Academy of Pediatrics, in the section of integrative medicine with very lively lister.
If you join that section, you will learn much more than I can possibly give in a session from many of my very brilliant colleagues, and we put our talks up on the list service.
Lots of questions, lots of chatter about patients and families, and what they want or don't want to use in their kids. Lots of discussion about probiotics, lots of discussion about CBD, to be honest with you, and other supplements, and I've learned things from my colleagues on this section.
I want to thank the Academy for allowing me to give this session, and I'm honored that you would interview me for this podcast.
Jessica: Thank you. Thank you for joining us. I appreciate your time. I've learned a lot and I know our audience did too. Thank you.
Dr Breuner: Thank you.