Herbal medicine use by children presenting for ambulatory anesthesia and surgery

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Herbal medicine use by children presenting for ambulatory anesthesia and surgery
   Herbal medicine use by children presenting  for ambulatory anesthesia and surgery SUZANNE CROWE  FFARCSIFFARCSI  AND BARRY LYONS  FFARCSIFFARCSI Department of Anaesthesia & Critical Care Medicine, Our Lady’s Hospital for Sick Children,Crumlin, Dublin, Ireland Summary Background : Herbal medicine use has become increasingly popularthroughout the world. Some of these agents may have seriousinteractions with anesthetic drugs. Children may potentially be morevulnerable to such interactions because of altered drug handling.While the prevalence of herbal medicine use by children with somechronic illnesses has been estimated, the incidence of this in apopulation of otherwise healthy children admitted for minor ambu-latory anesthesia and surgery is currently unknown.  Methods : Parents of 601 children presenting consecutively for ambu-latory surgery were asked to complete a questionnaire detailingadministration of herbal medicines to their child. Results : This study identified that 6.4 % of children were currentlytaking an herbal preparation; while a further 10.1 % had taken anherbal medicine in the past. Echinacea and arnica were the commonestused herbal remedies. A significant number of children had takenagents which may interact with anesthesia and surgery: St John’sWort, valerian, garlic and gingko. Information on herbal medicineswas mostly obtained by parents from nonmedical sources. Conclusions : A total of 16.6 % of children had a current or past historyof ingestion of herbal medicines. This finding may have implicationsfor the perioperative management of children presenting for day-casesurgery. Keywords:   medicine; herbal; anesthesia; children Introduction Recent literature suggests that a significant propor-tion of adults presenting for surgery and anesthesiaare self-administering herbal preparations (1,2).There have been several case reports highlightingthe dangers of herbal medicines taken in combina-tion with conventional prescribed medicines (3–5).In the context of anesthesia, where multiple drugsare administered over a short period of time, herbalproducts represent a potential risk to patient safety.This is particularly the case if the anesthetist is notaware that the patient is taking such a product. Areview of the subject by Ang-Lee concluded thatquestions relating to herbal medicine use shouldnow form part of our routine preoperative assess-ment (2). Correspondence to:  Barry Lyons, Department of Anaesthesia &Critical Care Medicine, Our Lady’s Hospital for Sick Children,Crumlin, Dublin 12, Ireland (email: barry.lyons@olhsc.ie). Pediatric Anesthesia 2004  14 : 916–919 916    2004 Blackwell Publishing Ltd  Little is known about the use of herbal medicinesin the pediatric population. As the majority of children admitted for day-case surgery are ASAI-II, few are taking prescribed medications. Thus,there is little possibility of interaction betweenconventional and herbal medicines in this popula-tion in the community (6). However, the potentialfor interaction with drugs administered during theinduction and maintenance of anesthesia does exist.This study aims to describe the extent of herbalmedicine use in children presenting for ambulatorysurgery and anesthesia. Methods Institutional Ethics Board approval for the study wasobtained. Six hundred and one children between theages of 1 month and 16 years sequentially admittedfor day-case surgery over a 10-week period wereenrolled in the study. The child’s parent/guardianwas asked to complete a questionnaire relating to theadministration of herbal medicines to their child.The questionnaire was completed in the presence of a nurse who was available to answer any queries.Recorded demographics included the health insur-ance status of the child (as a surrogate marker of economic status) in addition to age and gender. Thequestionnaire included a tick box list of commonlyused herbal medicines listed by their generic names.Proprietary names were not listed, but a space wasallowed for parents to include any product that theyhad given to their child which may have contained aherbal medicine. If the child was aged 6 months orless the parent was asked whether they were breastfeeding, and if so, whether they were concur-rently taking an herbal preparation. Results Sixhundredandonechildrenwereenrolledoveran8-weekperiod.Noparentdeclinedparticipation.Ofthe601 respondents, 39 (6.4 % ) children were currentlytaking an herbal preparation; while a further 61(10.1 % ) had taken an herbal medicine in the past.Nine of these children were under 1 year of age. One breastfeedingmotherwasagedtakingStJohn’swort.Echinacea was the most frequently administeredpreparation followed by arnica. Others included St John’s wort, gingko, valerian and ginseng (Table 1).The majority of parents had not informed theirfamily practitioner that the child was taking thismedicine (84.7 % ). An even greater number had notinformed the surgical team admitting the child thatday (89.8 % ). Children were administered herbalmedicines based on information obtained fromfamily friends (23.9 % ), media (18.1 % ), alternativepractitioners (10.1 % ), general practitioners (GP)(5.7 % ), pharmacy (5.7 % ), religious instruction(3.6 % ) and the internet (2.1 % ).Eighteen percent of children had private healthinsurance; of these 34.2 %  were taking an herbalmedicine compared with 15.4 %  of uninsured chil-dren ( v 2 ¼  19.389;  P  < 0.001). Discussion Anherbalmedicinemaybedefinedasaplant-derivedproductusedforthepurposeofhealthbenefit(7).Theuseofsuchtherapiesappearstobeincreasing(8),with20 % ofEnglishadults(9)andupto37 % ofAmericansusing herbal medicines in any calendar year (10).Studies carried out on adult surgical populationssuggest that 22–43 % are taking herbal medicines inthe perioperative period (1,11). Approximately 29 % of Australian children with asthma, and 14 %  of American adolescents with inflammatory bowel dis-ease use herbal medicines for treating their condition(12). In Washington, a prevalence study showed that8.4 %  of children used herbal remedies, while thefigure were almost 5 %  in a similar primary carepediatric setting in Detroit (13,14). However, no suchdatawasavailableforapediatricsurgicalpopulation.Our study has identified that 16.6 %  of childrenadmitted for day-case surgery were currently takingor had taken an herbal medicine in the past. Table 1 Herbal medicine use by children  Herbal medicine (HM)  % patients  ( n  ¼  100) Echinacea 35Arnica 31Camomile 11St Johns wort 7Garlic 4Valerian 3Ginkgo 3Ginseng 2Unknown type 12Multiple HMs 8 HERBAL MEDICINE USE 917   2004 Blackwell Publishing Ltd,  Pediatric Anesthesia ,  14 , 916–919  In this study, 16 %  of those taking an herbalmedicine were ingesting substances which mayimpact upon perioperative care. A further 12 %  of parents admitted to administering an herbal productto their child, but had no idea what it was. Increased bleeding has been reported with the use of gingkoand garlic, hypertension with ginseng, and excesssedation with St John’s wort, all of which arepertinent to anesthesia and surgery (2,15).  In vitro  studies indicate that garlic can inhibitplatelet aggregation (16), and several case reportssuggest that it may cause an increased bleedingtendency. These events, while anecdotal have hadserious consequences for some patients, including aspontaneous epidural hematoma and increasedperioperative bleeding (17–19). Gingko biloba,which may have beneficial effects on memory andconcentration, also has antiplatelet and anti-inflam-matory activity. Several case reports of intracranialhemorrhage and surgical bleeding have been repor-ted in patients taking gingko (20,21). It has beensuggested that gingko be avoided in patients takingNSAIDs (22).Both St John’s wort and valerian may potentiate orprolong the action of anesthetic agents, probablythrough the modulation of GABA neurotransmis-sion (2,3). One case report documented a 90-minrecovery time (to rousability) following a 10-mingeneral anesthetic in a healthy young woman; thedelay in recovery possibly being attributable to St John’s wort (3). Ginseng has been reported as havinghypoglycemic effects in patients with type-II diabe-tes (23). The two children taking ginseng in ourstudy were aged 2 and 4 years; so perioperativehypoglycemia was not a particular concern in thesepatients. However, the hypoglycemic effects of ginseng may be more pertinent in younger infants.There have been no reports of drug interactions between anesthetic medications and the two mostcommonly taken herbal medicines, echinacea andarnica. Echinacea is commonly used for the preven-tion and treatment of viral, bacterial and fungalinfections, particularly those affecting the upperrespiratory tract. Current evidence suggests thatwhile it may reduce the duration and severity of arespiratory tract infection, it is not effective asprophylaxis (15). However, long-term echinaceause may result in immunosupression, which maypotentially increase the risk of wound infection (24).Homeopathic arnica is widely believed to control bruising, reduce swelling and promote recoveryafter local trauma and many patients therefore takeit perioperatively. Its efficacy is debated with trialsgiving both positive and negative results (25,26).A recent systematic review of adverse effects of unconventional medicines in children identified 26case reports and series where serious illness mayhave resulted from the administration of suchunconventional therapies (27). This included a caseof toxic hepatitis induced by valerian ingestion. In arecent report, the WHO Monitoring Centre included8985 case reports of adverse events associated withherbal remedies between 1968 and 1997. Approxi-mately, 100 of these events occurred in childrenunder 10 years of age (28).Most parents had obtained information on herbalmedicines from nonmedical sources and had notinformed medical staff involved in the care of theirchild of herbal medicine use. This appears to bequite common. Kaye  et al . found that 70 % of patientstaking herbal medicines did not report this duringroutine preoperative assessment (11). Furthermore, astudy by Ottolini  et al.  suggested that while 86 % of children who used complementary or alternativemedicine would like to talk to their pediatricianabout such therapies, only 36 % actually did so (13).This reticence renders it impossible to prepare forany potential side-effects or interactions, or to offeradvice on their safe use in the perioperative period.This may include discontinuing herbal medicinesprior to surgery.The American Society for Anesthesiologists hasrecommended the discontinuation of all herbalmedicines 2 weeks prior to surgery (29), whileAng-Lee has proposed recommendations based oncurrent knowledge of the pharmacokinetics of theactive metabolites of these substances. He suggestsdiscontinuing kava and ephedra 24 h before, gingkomore than 36 h before, St Johns wort more than5 days before, and garlic more than a week beforeelective surgery.Ernst recently surveyed 23 systematic reviews of trials of herbal medicines, concluding that 11 yieldeda positive conclusion, nine positive but unconvinc-ing results and three a negative outcome (30). Thesame author, in an editorial, suggested that adverseevents may occur less frequently with herbal thanconventional medicines, and that their use may be918 S. CROWE AND B. LYONS   2004 Blackwell Publishing Ltd,  Pediatric Anesthesia ,  14 , 916–919   beneficial in cost terms (31). What is apparent is thatherbal medicines are here to stay. Survey datasuggests that annual expenditure on herbal medi-cines may be as much as £240 million in the UK, and£1.3 billion in Germany (31,32). It is thus incumbentupon anesthetists to educate themselves about her- bal medicines, including their benefits and risks. It isalso essential that questions regarding alternativemedical therapies are included during patient eval-uation at GP and surgical clinics, and duringanesthetic preoperative visits, in order to optimizeperioperative care.In conclusion, this study identified that approxi-mately one-sixth of children attending for day-casesurgical procedures had a history of current orprevious ingestion of an herbal remedy. This infor-mation was not volunteered without direct ques-tioning in the vast majority of cases. It is imperativethat anesthetists caring for children are aware of allmedications, both conventional and alternative, thata child is taking in order to provide the best possiblelevel of care. References 1 Tsen LC, Segal S, Potheir M  et al.  Alternative medicine use inpresurgical patients.  Anesthesiology  2000;  93:  148–151.2 Ang-Lee MK, Moss J, Yuan CS. Herbal medicines and peri-operative care.  JAMA  2001;  286:  208–216.3 Crowe S, McKeating K. Delayed emergence and St John’s wort.  Anesthesiology  2002;  96:  1025–1027.4 Piscitelli SC, Burstein AH, Chaitt D  et al.  Indinavir concentra-tions and St John’s wort.  Lancet  2000;  355:  547–548.5 Ruschitzka F, Meier PJ, Turina M  et al.  Acute heart transplantrejection due to St John’s wort.  Lancet  2000;  355:  548–549.6 Davis MP, Darden PM. Use of complementary and alternativemedicine by children in the United States.  Arch Pediatr Adolesc Med  2003;  157:  393–396.7 Bauer BA. Herbal therapy: what the clinician needs to know tocounsel patients effectively.  Mayo Clin Proc  2000;  75:  835–841.8 Ernst E. Prevalence of use of complementary/alternativemedicine: a systematic review.  Bull World Health Organ  2000; 78:  252–257.9 Thomas KJ, Nicholl JP, Coleman P. Use and expenditure oncomplementary medicine in England: a population basedsurvey.  Complement Ther Med  2001;  9:  2–11.10 Brevoort P. The booming US botanical market: a newoverview.  Herbalgram  1998;  44:  33–46.11 Kaye AD, Clarke RC, Sabar R  et al.  Herbal medications:current trends in anesthesiology practice – a hospital survey.  J Clin Anesth  2000;  12:  468–471.12 Ernst E. Herbal medicines for children.  Clin Pediatr  2003;  42: 193–196.13 Ottolini MC, Hamburger EK, Loprieato JO  et al.  Comple-mentary and alternative medicine use among children in theWashington, DC area.  Ambul Pediatr  2001;  2:  122–125.14 Sawni-Sikand A, Schubiner H, Thomas RL. Use of comple-mentary/alternative therapies among children in primary carepaediatrics.  Ambul Pediatr  2002;  2:  104–110.15 Hodges PJ, Kam PCA. The perioperative implications of herbalmedicines.  Anaesthesia  2002;  57:  889–899.16 Bordia A. Effect of garlic on human platelet aggregation invitro.  Atherosclerosis  1978;  30:  355–360.17 Rose KD, Croissant PD, Parliament CF. Spontaneous spinalepidural haematoma with associated platelet dysfunction fromexcessive garlic ingestion: a case report.  Neurosurg  1990;  26: 880–882.18 German K, Kumar U, Blackford HN. Garlic and the risk of TURP bleeding: a case report.  Br J Urol  1995;  76:  518.19 Burnham BE. Garlic as a possible risk for postoperative bleeding.  Plast Reconstr Surg  1995;  95:  213.20 Benjamin J, Muir T, Briggs K  et al.  A case of cerebral hae-morrhage – can Gingko biloba be implicated?  Postgrad Med J   2001;  77:  112–113.21 Fessenden JM, Wittenbern W, Clarke L. Ginko biloba. A casereport of herbal medicine and bleeding postoperatively from alaparoscopic cholecystectomy.  Am Surg  2001;  67:  33–35.22 Miller LG. Herbal medicines. Selected clinical considerations,focusing on known or potential drug-herb interactions.  Ann Int Med  1998;  158:  2200–2211.23 Sotaniemi EA, Haapakoski E, Rautio A. Ginseng therapy innon-insulin-dependent diabetic patients.  Diabetes Care  1995;  18: 1373–1375.24 Boullata JI, Nace AM. Safety issues with herbal medicine. Pharmacotherapy  2000;  20:  257–269.25 Knuesel O, Weber M, Suter A. Arnica Montana gel in osteo-arthritis of the knee: an open, multicenter clinical trial.  AdvTher  2002;  19:  209–218.26 Stevinson C, Devaraj VS, Fountain-Barber A  et al.  Homeopa-thic arnica for prevention of pain and bruising: randomizedplacebo-controlled trial in hand surgery.  J R Soc Med  2003;  9: 60–65.27 Ernst E. Serious adverse effects of unconventional therapies forchildren and adolescents: a systematic review of recent evi-dence.  Eur J Pediatr  2003;  162:  72–80.28 Farah MH, Edwards R, Lindquist M  et al.  International mon-itoring of adverse health effects associated with herbal medi-cines.  Pharmacoepidemiol Drug Saf   2000;  9:  105–112.29 Available at: http://www.asahq.org/Newsletters/2000/02-00/herbal0200.html.30 Ernst E. Herbal medicinal products: an overview of systematicreviews and meta-analysis.  Perfusion  2001;  14:  398–404.31 Ernst E. Herbal medicines put into context.  BMJ   2003;  327:  881–882.32 Seghal A, Hall JE. Herbal medicines – harmless or harmful.  Anaesthesia  2002;  57:  947–948.  Accepted 8 January 2004 HERBAL MEDICINE USE 919   2004 Blackwell Publishing Ltd,  Pediatric Anesthesia ,  14 , 916–919
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