Use of CAM

To date, there have been 5 studies documenting the use of CAM in children with JIA, arthralgia, connective tissue disease (systemic lupus erythematosus, dermatomyositis, scleroderma, or vasculitis), or other pediatric conditions treated by pediatric rheumatologists (including fibromyalgia and rare diagnoses such as sarcoidosis). Of these studies, 4 were cross-sectional and 1 described the use of CAM during a 1 -year period. According to studies in pediatric rheumatology, the percentage of CAM use ranges between 34% and 92%. In the longitudinal study, use of CAM ranged between 10% and 24% for the various 3-month intervals, and 51% of participants had used CAM in the past to treat their JIA symptoms. Among these participants, 36% used CAM for more than a 3 -month interval.

Types of CAM Used

According to the study by Southwood and colleagues conducted in 1990 surveying 53 children with JIA from Canada (n = 18), New Zealand (n = 4), and Australia (n = 31) attending a summer camp, 70% of participants reported having used unconventional therapies. The most common therapies were copper bracelets, diet modifications, natural health products (NHPs), and chiropractic. High CAM use could be explained in part by the high disease severity of these children. In 1999, a study conducted by Hagen and colleagues on 141 children attending an outpatient rheumatology clinic and diagnosed with one of arthritis, connective tissue disease (systemic lupus erythematosus, dermatomyositis, scleroderma, or vasculitis), or other pediatric conditions (including fibromyalgia, rare diagnoses such as sarcoidosis, and those illnesses not yet diagnosed) at a tertiary care children’s hospital, 64% of the children used at least one type of CAM in the past year and half of them, more than one type. The most used interventions were vitamins, minerals, relaxation techniques, chiropractic, and homeopathy. High CAM use could be explained by the emphasis given to nutritional supplements in the survey. In fact, the use was lower (51.8%) when vitamins and minerals were excluded. Zebracki and colleagues also showed a high level of CAM use in 36 Latin American children with JIA (n = 17) and symptoms of arthralgia (n = 19) aged 6 to 16 years (56%) followed up at a rheumatology clinic at a tertiary care children’s hospital. The most popular types of interventions were prayer, massage therapy, and meditation/ relaxation. In 2007, Rouster-Stevens and colleagues surveyed 52 parents of children with JIA at a pediatric rheumatology clinic that cared for these children from birth to the age of 21 years. CAM was used in the previous 30 days in 92% of the families, including massage therapy, vitamins and other supplements, diets, and stress management techniques. Finally, Feldman and colleagues conducted a preliminary analysis of a cross-sectional study on 118 children with JIA aged 2 to 18 years, followed up at 2 outpatient rheumatology clinics. The study was continued for a 1-year period from 2003 to 2004. In this study, 34% of the patients used CAM, with the most commonly used modalities being naturopathy, acupuncture, chiropractic, and diets. In the longitudinal continuation of this study (n = 182 children with JIA at baseline), 40% of the participants used more than one type of CAM, particularly diets and supplements, chiropractic, and naturopathy. Differences in use of CAM may be explained by questionnaires, each assessing a different range of CAM types because of different definitions of CAM, different time frames, as well as populations with different sociodemographic and disease-related characteristics.

Factors Related to CAM Use

Some parents of children with JIA may seek CAM if they fear side effects of conventional medications and perceive that the child’s condition is not improving with such therapy. Most parents use CAM to relieve pain in their children. CAM was also used to improve overall well-being in 20% of the cases.

Factors associated with CAM use in children with JIA include longer disease duration, presence of more than one illness, previous CAM use by parents themselves, and parents’ perception that medications are not helping. Older age may be associated with CAM use but could also be a reflection of disease duration. In addition, parents who considered themselves as Canadian as opposed to belonging to a specific ethnic group were higher users of CAM according to Feldman’s cross-sectional study but not according to the longitudinal analysis of the same cohort by Toupin April and colleagues. Factors associated with the continued use of CAM (use in more than a single 3-month interval) in this population were previous parental use and parents’ perceived unhelpfulness of the prescribed medications. Use of CAM also seems to be related to improved psychological functioning in children with arthralgia. Also, according to the 1-year longitudinal study, children who used CAM did not seem to show improved outcomes, at least over this relatively short term but seemed to be more adherent to conventional treatment according to the rheumatologist. Finally, the level of acculturation (ie, language, ethnic identity, cultural heritage, and ethnic interaction) was not found to be associated with CAM use. None of the studies in pediatric rheumatology have examined whether ethnicity was related to the type of CAM used. However, prayer seemed to be used more extensively in a study of Latin American children, whereas vitamins, supplements, and special diets were most commonly used in studies including children from other ethnic backgrounds.

Costs Associated with CAM

None of the studies on JIA mention the financial costs of using CAM. However, one study conducted in Quebec, Canada mentioned the methods of payment for the use of CAM. Among the episodes of CAM use, 69% were paid by parents, 18% were paid by private insurance, 8% were free, 5% were paid by another source, and less than 1% was paid by the provincial universal insurance plan. The CAM treatments that were paid for most often by parents were dietary treatments (90%), chiropractic (81%), and homeopathy (75%), whereas those paid for most often by private insurance were acupuncture (46%), massage (29%), and osteopathy (27%). However, these results depend strongly on the extent of insurance coverage available to each participant, whether public or private. In the general American pediatric population, the average annual amounts spent per person on CAM visits and remedies were $73.40 and $13.06, respectively. Estimates of the 1996 national pediatric population on annual expenditures on CAM visits and remedies were $127 million and $22 million, respectively, with higher costs for children with a chronic condition.

Perceived Effectiveness and Side Effects of CAM

Many parents reported positive results of CAM. Among parents of Latin American children with JIA or arthralgia, 80% thought that CAM was somewhat helpful. Another study showed that the therapies perceived to be the most effective (rated on a 4-point scale from not helpful to very helpful) were support groups, spiritual healing, rubbing menthol-based balm on the joints, and vitamin D. Overall, CAM therapies showed a perception of helpfulness similar to conventional medication but with fewer perceived side effects. Finally, in another study, parents of children with JIA reported that 28% of episodes of use were not beneficial and 23% were somewhat beneficial, while 49% were moderately to highly beneficial, with most CAM types leading to a slight to moderate improvement.

Use of CAM

To date, there have been 5 studies documenting the use of CAM in children with JIA, arthralgia, connective tissue disease (systemic lupus erythematosus, dermatomyositis, scleroderma, or vasculitis), or other pediatric conditions treated by pediatric rheumatologists (including fibromyalgia and rare diagnoses such as sarcoidosis). Of these studies, 4 were cross-sectional and 1 described the use of CAM during a 1 -year period. According to studies in pediatric rheumatology, the percentage of CAM use ranges between 34% and 92%. In the longitudinal study, use of CAM ranged between 10% and 24% for the various 3-month intervals, and 51% of participants had used CAM in the past to treat their JIA symptoms. Among these participants, 36% used CAM for more than a 3 -month interval.

Types of CAM Used

According to the study by Southwood and colleagues conducted in 1990 surveying 53 children with JIA from Canada (n = 18), New Zealand (n = 4), and Australia (n = 31) attending a summer camp, 70% of participants reported having used unconventional therapies. The most common therapies were copper bracelets, diet modifications, natural health products (NHPs), and chiropractic. High CAM use could be explained in part by the high disease severity of these children. In 1999, a study conducted by Hagen and colleagues on 141 children attending an outpatient rheumatology clinic and diagnosed with one of arthritis, connective tissue disease (systemic lupus erythematosus, dermatomyositis, scleroderma, or vasculitis), or other pediatric conditions (including fibromyalgia, rare diagnoses such as sarcoidosis, and those illnesses not yet diagnosed) at a tertiary care children’s hospital, 64% of the children used at least one type of CAM in the past year and half of them, more than one type. The most used interventions were vitamins, minerals, relaxation techniques, chiropractic, and homeopathy. High CAM use could be explained by the emphasis given to nutritional supplements in the survey. In fact, the use was lower (51.8%) when vitamins and minerals were excluded. Zebracki and colleagues also showed a high level of CAM use in 36 Latin American children with JIA (n = 17) and symptoms of arthralgia (n = 19) aged 6 to 16 years (56%) followed up at a rheumatology clinic at a tertiary care children’s hospital. The most popular types of interventions were prayer, massage therapy, and meditation/ relaxation. In 2007, Rouster-Stevens and colleagues surveyed 52 parents of children with JIA at a pediatric rheumatology clinic that cared for these children from birth to the age of 21 years. CAM was used in the previous 30 days in 92% of the families, including massage therapy, vitamins and other supplements, diets, and stress management techniques. Finally, Feldman and colleagues conducted a preliminary analysis of a cross-sectional study on 118 children with JIA aged 2 to 18 years, followed up at 2 outpatient rheumatology clinics. The study was continued for a 1-year period from 2003 to 2004. In this study, 34% of the patients used CAM, with the most commonly used modalities being naturopathy, acupuncture, chiropractic, and diets. In the longitudinal continuation of this study (n = 182 children with JIA at baseline), 40% of the participants used more than one type of CAM, particularly diets and supplements, chiropractic, and naturopathy. Differences in use of CAM may be explained by questionnaires, each assessing a different range of CAM types because of different definitions of CAM, different time frames, as well as populations with different sociodemographic and disease-related characteristics.

Factors Related to CAM Use

Some parents of children with JIA may seek CAM if they fear side effects of conventional medications and perceive that the child’s condition is not improving with such therapy. Most parents use CAM to relieve pain in their children. CAM was also used to improve overall well-being in 20% of the cases.

Factors associated with CAM use in children with JIA include longer disease duration, presence of more than one illness, previous CAM use by parents themselves, and parents’ perception that medications are not helping. Older age may be associated with CAM use but could also be a reflection of disease duration. In addition, parents who considered themselves as Canadian as opposed to belonging to a specific ethnic group were higher users of CAM according to Feldman’s cross-sectional study but not according to the longitudinal analysis of the same cohort by Toupin April and colleagues. Factors associated with the continued use of CAM (use in more than a single 3-month interval) in this population were previous parental use and parents’ perceived unhelpfulness of the prescribed medications. Use of CAM also seems to be related to improved psychological functioning in children with arthralgia. Also, according to the 1-year longitudinal study, children who used CAM did not seem to show improved outcomes, at least over this relatively short term but seemed to be more adherent to conventional treatment according to the rheumatologist. Finally, the level of acculturation (ie, language, ethnic identity, cultural heritage, and ethnic interaction) was not found to be associated with CAM use. None of the studies in pediatric rheumatology have examined whether ethnicity was related to the type of CAM used. However, prayer seemed to be used more extensively in a study of Latin American children, whereas vitamins, supplements, and special diets were most commonly used in studies including children from other ethnic backgrounds.

Costs Associated with CAM

None of the studies on JIA mention the financial costs of using CAM. However, one study conducted in Quebec, Canada mentioned the methods of payment for the use of CAM. Among the episodes of CAM use, 69% were paid by parents, 18% were paid by private insurance, 8% were free, 5% were paid by another source, and less than 1% was paid by the provincial universal insurance plan. The CAM treatments that were paid for most often by parents were dietary treatments (90%), chiropractic (81%), and homeopathy (75%), whereas those paid for most often by private insurance were acupuncture (46%), massage (29%), and osteopathy (27%). However, these results depend strongly on the extent of insurance coverage available to each participant, whether public or private. In the general American pediatric population, the average annual amounts spent per person on CAM visits and remedies were $73.40 and $13.06, respectively. Estimates of the 1996 national pediatric population on annual expenditures on CAM visits and remedies were $127 million and $22 million, respectively, with higher costs for children with a chronic condition.

Perceived Effectiveness and Side Effects of CAM

Many parents reported positive results of CAM. Among parents of Latin American children with JIA or arthralgia, 80% thought that CAM was somewhat helpful. Another study showed that the therapies perceived to be the most effective (rated on a 4-point scale from not helpful to very helpful) were support groups, spiritual healing, rubbing menthol-based balm on the joints, and vitamin D. Overall, CAM therapies showed a perception of helpfulness similar to conventional medication but with fewer perceived side effects. Finally, in another study, parents of children with JIA reported that 28% of episodes of use were not beneficial and 23% were somewhat beneficial, while 49% were moderately to highly beneficial, with most CAM types leading to a slight to moderate improvement.