Chapter 30 Paediatrics

OVERVIEW OF PAEDIATRIC CONSIDERATIONS

Working with children can be extremely rewarding, but it is very different from treating adults. Children often face very different medical conditions to adults and require specialised care. Practitioners need to be aware of children’s special needs, the sensitivity of the child, and the child’s parents and their siblings. While many childhood conditions can be treated in the family home, it is wise to seek the help of medical intervention when a condition is worsening, and to do so as soon as possible because children (especially babies) can become gravely ill quite quickly. Conversely, they can recover quickly once appropriate intervention is commenced. Children’s immune systems and nervous systems develop rapidly, and this also needs to be considered at all times when embarking on any health intervention.

The terminology for the classification of the paediatric patient is used in this chapter according to the definitions given at the International Conference on Harmonisation (ICH).¹ The ICH recommended age should be classified in completed days, months or years following the stage categories of:

1. preterm newborn infants

2. term newborn infants (0–27 days)

3. infants and toddlers (28 days to 23 months)

4. children (2–11 years)

5. adolescents (12 to 16 or 18 years depending on the region).

The United Nations’ Convention on the Rights of the Child defines a ‘minor’ as anyone under the age of 18 years.²

The use of complementary and alternative medicine (CAM) in paediatric treatment is prevalent.³^–⁵ Studies have shown that the use of one or more CAM therapies for treatment of children range between 20 and 70% of cases. The rates for general paediatric patients are 20–30%, for adolescents 30–70% and for paediatric patients with chronic or recurrent conditions, including those considered to be incurable, 30–70%.^3,⁴ CAM practices used most commonly for children include infant massage, general massage and vitamin and herbal therapies. Demographic data for paediatric treatment reflect that seen in generalised populations, showing that the parents of children being given CAM therapies are often more educated and affluent. They choose to use CAM because they believe it is natural, lower cost, more effective, has been recommended by family or friends, are worried about possible side effects of conventional therapies, or conventional therapies have failed them in the past.^3,^4,⁶

Ethical and legal considerations

Cohen and Kemper raised some questions about the clinically appropriate use of CAM in paediatrics.⁵ They suggested that the non-judicious use of various CAM therapies may cause direct harm (or indirect harm) by creating an unwarranted financial and emotional burden. They recommended a series of questions that practitioners treating paediatric patients could ask when deciding how to advise patients on the use of CAM. These questions are:

1. Do parents elect to abandon effective care when the child’s condition is serious or life-threatening?

2. Will use of the CAM therapy otherwise divert the child from imminently necessary conventional treatment?

3. Are the CAM therapies selected known to be safe and/or effective?

4. Have the proper parties consented to the use of the CAM therapies?

5. Is the risk:benefit ratio of the proposed CAM therapy acceptable to a reasonable, similarly situated clinician, and does the therapy have at least minority acceptance or support in the medical literature?⁵

As the body of evidence concerning CAM increases, there will be more proof (or otherwise) as to the efficacy and safety of certain CAM therapies and these ethical considerations will become less clouded.

Cohen and Kemper also concluded that paediatric use of CAM therapies may raise legal as well as clinical concerns.⁵ A cautious yet balanced approach ideally can help guide the specialised paediatric naturopath towards clinical advice (including referral) that is clinically responsible, ethically appropriate and legally defensible. Employing such an approach—one that embraces both clinical and legal concerns—can help to protect the child’s welfare as new parameters for integrative health care unfold.

Most research on CAM therapies is being conducted on adults and may therefore not be directly applicable to paediatric populations. There are some specific considerations that need to be made when looking at the particular aspects of conducting clinical trials on the paediatric population. These include the ongoing changes to children’s bodies (their metabolism and developmental stage), their changing social relationships and their vulnerability and dependence upon others.

Until there are much more reliable research data on CAM in paediatric populations, practitioners will need to continue to extrapolate data and adjust the adult information to the child, being mindful of the child’s unique circumstances.

PAEDIATRIC MEDICATION CONSIDERATIONS

The consensus is that children do not equate to small adults.⁷ There are marked differences in pathology, physiology, pharmacokinetics and pharmacodynamics between children and adults.⁸^–¹⁰ The efficacy of a medication depends on the practitioner selecting an appropriate preparation, calculating the correct dosage and motivating the family to ensure regular administration.¹¹

There are some important considerations when deciding the dose of medications at different life stages. Drugs are metabolised very differently in neonates and children compared to adults. Absorption is affected by differences in gastric acid secretion, bile salt formation, gastric emptying, intestinal motility and microflora.⁷ These are mostly reduced in a neonate and may also be reduced—though sometimes raised—in an ill child. The distribution of the volume of drugs in children can change with age because of the differences in the body’s composition of minerals, lipids, proteins and water (see Figure 30.1 below); plasma protein binding capacity also changes with age. Drug elimination can be longer in babies than adults. So, when medicating babies and children less than 12 years old, body weight and age should be considered.⁸ (See Table 30.1 with formulas below.)

Figure 30.1 Changes in body proportions of body composition with growth and ageing

Source: Adapted from Puig M, Body composition and growth. In Walker WA. Watkins JB, eds. Nutrition in pediatrics. 2nd edn. Hamilton, Ontario, BC: Decker, 1996.

Table 30.1 Calculating medication dosages ^12,¹³

AGE	RULE	FORMULA
Birth to 12 months	Ausberger’s rule
1–2 years	Fried’s rule (or Ausberger’s rule)
2–12 years	Young’s rule or
	Ausberger’s rule or
	Clarke’s rule
12–16 years	Ausberger’s rule
16+ years	Unless the teenager is of small stature, adult doses may be considered.

Individual practitioners will have a preference for one formula over another when selecting a dose for children. Table 30.1 can be used to guide those in doubt when considering a herbal formula. Ausberger’s rule and Clarke’s rule for calculations of paediatric doses of medications are based on weight as opposed to age and may be more suitable to allow for the faster metabolism of children at certain ages.¹² Fried’s rule and Young’s rule are based on age alone.

Hepatic metabolism

Medications are metabolised by enzymatic and metabolic reactions. Phase I activity for drug metabolism is reduced in neonates, increases progressively during the first 6 months of life, slows during adolescence, and usually attains adult rates by late puberty.^8,⁹ Neonates metabolise medications much more slowly than adults do. By 6 months of age the immature reactions involving acetylation, glucuronidation and conjugation with amino acids have matured to adult levels.⁹ The metabolic pathways for phase II reactions reach adult levels by 3–4 years of age.^9,¹⁴^–¹⁶

Digestive flora

Colonisation of the gastrointestinal tract begins at birth and is usually established by week 1. The type of microorganism will depend on hygiene and diet. Bifidobacterium is the most prolific organism in a breastfed baby.¹³ It is estimated that the number of aerobic and anaerobic bacteria in newborns is up to a total of 10¹⁰/g wet weight.¹⁷ Implications of this altered flora are discussed in the chapters on irritable bowel syndrome, atopic skin disorders and asthma.

Nutrition in children

The physiological differences in children when compared to adults also result in differing nutritional requirements for children. This reflects the population’s unique needs for growth and development, as well as their differing maintenance requirements due to higher metabolisms. The estimated average requirements for the main nutrients are listed in Tables 30.2 and 30.3.¹⁸^–²⁰

Table 30.2 Vitamins

Table 30.3 Main minerals

Herbal medicine in children

The conditions encountered in paediatric practice may be different from those encountered in general practice (for example, otitis media and colic). Therefore the herbal medicines most commonly used will also differ. Table 30.4 outlines common paediatric conditions and herbal medicines used to treat these conditions.

Table 30.4 Commonly used herbs in paediatrics according to herbal tradition ^13,^18,²¹^–²⁵

MAIN CONDITIONS	MAIN TREATMENT ACTIONS	COMMON HERBS
Infants and toddlers
Colic	Carminative	Mentha piperita, Foeniculum vulgare, Matricaria recutita, Melissa officinalis Essential oils: Matricaria recutita 2 drops plus 2 drops of Foeniculum vulgare or Anaethum graveolens
Common cold	Immune system-enhancing Circulatory stimulant Antiseptic	Echinacea spp., Andrographis paniculata, Astragalus membranaceus (not in the acute phase) Zingiber officinale Verbascum thapsis and Thymus vulgaris Glycyrrhiza glabra
Constipation	Laxatives Demulcent Spasmolytic Hydrative	Iris versicolor, Angelica polymorpha, Rumex crispus, Taraxacum officinale (radix), Glycyrrhiza glabra Ulmus fulva Matricaria recutita, Melissa officinalis, Mentha piperita
Children
Respiratory tract infections	Anticatarrhals Respiratory demulcents Expectorants Mucolytics Antitussives Antiseptic Mucous membrane trophorestorative	Solidago virgaurea, Hydrastis canadensis Althea officinalis, Chondus crispus Pelargonium sidoides, Grindelia camporum, Inula helenium Allium sativum, Amoracia rusticana Prunus serotina, Glycyrrhiza glabra Thymus vulgaris, Allium sativum, Inula helenium, Pelargonium sidoides Hydrastis canadensis
Fever	Diaphoretics Cooling bitters	Mentha piperita, Achillea millefolium, Sambucus nigra Taraxacum officinale, Gentiana lutea
Allergy	Antiallergy	Albizzia lebbeck, Scutellaria baicalensis
Asthma	Bronchodilator Expectorant Bronchodilator Trophorestorative Anticatarrhal	Adhatoda vasica Coleus forskohlii Hydrastis canadensis
Adolescents
Acne	Depurative Hypoglycaemic Immune modulating Anti-inflammatory	Rumex crispus, Berberis aquifolium, Arctium lappa Galega officinalis, Gymnema sylvestre Echinacea spp., Andrographis paniculata Glycyrrhiza glabra, Buplurum falcatum, Rehmannia glutinosa
Warts	Antiviral Immunomodulating	Thuja occidentalis Echinacea spp.
Stress	Adrenal tonic Adaptogen Nervine	Glycyrrhiza glabra Eleutherococcus senticosus, Withania somnifera Hypericum perforatum, Scutellaria lateriflora, Passiflora incarnata