Focus on Alternative and Complementary Therapies
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Focus Alternat Complement Ther©2005 Pharmaceutical Press
Focus Altern Complement Ther 2005; 10: 177–80
The use of CAM has dramatically increased in recent years among adults and children in the USA, Australia and Europe.1–3 Forty-two percent of adult Americans have tried CAM1 as compared to 50% of the Australian population2 and 25% of the population in the UK.3 In 1994, the percentage of US patients treated in general paediatric practices who used CAM was approximately 11%,4 increasing to 21% in 1997.5 This percentage is substantially higher for children and families faced with chronic and recurrent conditions.6–8
Asthma is one of the most prevalent chronic diseases affecting children and adolescents worldwide.9,10 Standard asthma treatment consists of daily preventive medications, such as inhaled corticosteroids for persistent asthma and bronchodilators for acute exacerbations.11 Despite improvements in pharmacological interventions, many parents of children with asthma turn to CAM therapies in search of a natural solution for their child’s chronic health problem. Prior reports have suggested that more than 80% of children and adolescents with asthma use CAM.12,13 However, studies of the effectiveness of CAM therapies in children with asthma are limited. The aim of this focus article is to assess the effectiveness of CAM treatment options for paediatric asthma based on the evidence from systematic reviews, meta-analysis and clinical trials.
We conducted electronic literature searches of Medline and The Cochrane Library databases from their inception until March 2005. We used the following search terms: ‘alternative medicine’, ‘complementary medicine’ and ‘asthma’. We limited the search to children (aged 0–18 years) and articles published in English. The original studies, when available, were compared with systematic reviews. PubMed was also searched for the same restrictions and keywords as well as the additional restriction of RCT and keywords of ‘acupuncture’, ‘chiropractic’, ‘massage’, ‘fatty acids’, ‘fish oil’, ‘magnesium’, ‘vitamin C’, ‘ascorbic acid’, ‘homoeopathy’ and ‘herbal medicine’. The results indicate the evidence for the following CAM therapies.
A Cochrane review (updated March 2003) assessed the evidence of acupuncture for chronic asthma.14 It identified 11 CCTs, of which one study involved children15 and one involved children and adults.16 The systematic review and meta-analysis by Martin et al.17 revealed two additional studies involving children.18,19
Hirsch et al.15 compared the effect of laser acupuncture with sham laser acupuncture on the lung function of 39 children (aged 5–17 years) with mild to moderate asthma. Tashkin et al.16 conducted a crossover study of 25 subjects aged 8–70 years with moderate to severe asthma using needle and sham acupuncture to determine the effect of acupuncture on lung function, medication use and symptom frequency. No significant difference in the outcome measures was found between or within groups in both studies.
Chow et al.18 in a single-blinded trial of 16 children with exercise-induced asthma compared the effects of needle auricular acupuncture and sham acupuncture on forced expiratory volume in 1 s (FEV1). The authors did not find a significant difference in the percentage fall of FEV1 after exercise between the two groups. Fung et al.19 reported that real acupuncture provided better protection against exercise-induced asthma than did sham acupuncture, as evidenced by the change in pulmonary function in 19 children with mild to moderately severe asthma. Despite the controversial findings of the above two studies, more data from rigorous clinical trials are required before recommendation can be made for the practice of acupuncture in the treatment of childhood asthma.
Two RCTs of chiropractic spinal manipulation in children were identified.20,21 Balon et al.20 conducted an RCT of 80 children aged 7–16 years with symptomatic asthma confirmed by positive beta-agonist or methacholine challenge tests to determine the effectiveness of spinal manipulation in the management of mild to moderate asthma. Subjects were randomly assigned to receive either active or simulated chiropractic manipulation for 4 months. All participants were fully blinded to the treatment assignment except for the treating chiropractor and one investigator not involved in outcome assessment. The primary outcome measure was the change from baseline in the peak expiratory flow, measured in the morning before the use of a broncho-dilator, at 2 months and at 4 months. Despite an improvement in symptoms and quality of life, and a reduction in beta-agonist use, these changes were not significantly different between the two groups. The authors concluded that the addition of chiropractic spinal manipulation to usual medical asthma care had no effect on the control of childhood asthma.
Bronfort et al.21 conducted a pilot RCT of 36 children aged 6–17 years with asthma to determine if chiropractic spinal manipulative therapy in addition to medical management resulted in clinically important changes in asthma-related outcomes as compared to sham therapy. However, the active and sham groups were dissimilar at baseline with regard to asthma severity classification and patient-rated severity. Thus, no statistical comparisons between the two groups were made. After 3 months of intervention, subjects in the active spinal manipulation group rated their quality of life higher and their asthma severity lower as compared to baseline. However, there were no statistically significant changes in objective lung function tests and patient- and parent-rated daytime and night-time asthma symptoms as recorded in the diary. It is possible that the improvements in quality of life seen in both studies might have resulted from frequent professional attention and increased compliance with medications under the trial conditions. Further rigorous clinical trials are required to assess the effectiveness of spinal manipulation in the treatment of asthma in children.
One RCT was identified that assessed the effect of massage on asthma outcomes in children.22 Field et al. randomly assigned 32 children (16 aged 4–8 years and 16 aged 9–14 years) to receive either parentally administered massage or relaxation therapy for 20 min before bedtime for 30 days. Using salivary cortisol levels, video-recorded behaviour and pulmonary function tests as measures of intervention effects, the authors found a significant difference in the pulmonary function tests of the massage group of younger subjects, compared with their baseline values. In the older subjects, only one measure of the pulmonary function (forced expiratory flow 25–75%) improved. The younger children who received massage therapy showed an immediate decrease in anxiety, improved attitude towards asthma and decreased salivary cortisol levels after massage, compared with their baseline. The older children who received massage therapy also reported lower anxiety after the massage and improved attitude towards asthma. These changes were not observed in the relaxation group. Despite this evidence from a single study, larger RCTs are needed to determine whether massage therapy is an effective treatment for childhood asthma.
A Cochrane review23 (updated February 2002) assessed the effect of fish oil supplementation and a diet high in marine n-3 fatty acids on asthma. Of nine identified RCTs, only two involved children. Nagakura et al.24 determined the effects of dietary supplementation with fish oil for 10 months in 29 children with asthma hospitalised in a long-term facility. The authors compared asthma symptom scores and responsiveness to the acetylcholine inhalation test between subjects randomly assigned to receive fish oil capsules or control capsules containing olive oil. This study revealed that asthma symptom scores and responsiveness to acetylcholine decreased in the fish oil group as compared to control group.
Hodge et al.25 conducted a double-blind RCT for 6 months in 39 children (aged 8–12 years) receiving either fish oil capsules plus canola oil and margarine (omega-3 group) or safflower oil capsules plus sunflower oil and margarine (omega-6 group). The authors concluded that dietary supplementation with omega-3 fatty acids increased the plasma levels of these fatty acids, reduced stimulated tumour necrosis factor alpha production, but had no effect on the clinical severity of asthma. Because of the limited data available to date in children, it is difficult to come to any firm conclusions regarding the benefits of fish oil supplementation in this age group.
Prior studies have suggested that a low dietary intake of antioxidant nutrients such as magnesium and vitamin C may be associated with reduced lung function and bronchial hyper-reactivity.26–29 Bede et al.26 conducted an RCT in 89 children to determine whether or not oral magnesium supplementation over a 12-week period affects the magnesium status and bronchodilator use in children with stable mild or moderate persistent asthma. The authors found a significant urinary magnesium loss in the placebo group and reduction in bronchodilator use in the magnesium supplementation group. Although this study suggests the benefit of oral magnesium supplementation in children with asthma, a single study does not provide sufficient evidence to recommend the use of oral magnesium in clinical practice.
A Cochrane review30 (updated April 2004) of vitamin C supplementation for asthma identified eight RCTs of which one included children31 and one both children and adults.32 Anderson et al.31 examined the impact of intravenous vitamin C injection on lung function and immunological markers in 16 white South African children. The authors concluded that injection of vitamin C had no detectable effects on the degree of exercise-induced bronchoconstriction but reduced IgE levels, although not to a significant extent.
Cohen et al.32 in a randomised double-blind placebo-controlled crossover study determined the effect of a single-dose vitamin C administration on FEV1 in 20 patients (aged 7–28 years) with exercise-induced asthma. Vitamin C administration did not change the results of pulmonary function tests after 1 h. Although four of five subjects who had a protective effect of vitamin C on exercise-induced asthma continued to receive vitamin C for 2 more weeks, no control or placebo arm for this group was selected. The authors concluded that vitamin C may have a protective effect on airway hyper-reactivity in some patients with exercise-induced asthma. However, the efficacy of vitamin C in preventing exercise-induced asthma cannot be predicted. The limited evidence of the role of vitamin C in children with asthma precludes it from recommendation in the treatment or management of asthma.
A Cochrane review33 (updated July 2003) of the effect of homoeopathy on chronic asthma revealed six RCTs, two of which recruited children.34,35 Neither of these two studies found a significant difference between the treatment and placebo groups in terms of intensity, frequency and duration of asthma exacerbations,34 quality of life scores, peak expiratory flow rates, frequency of inhaler use or missed school days.35
A systematic review36 of RCTs of the effect of extracts from dried ivy leaves (Hedera helix L.) in the treatment of asthma in children revealed three studies but only one study37 used a placebo control. A double-blind, crossover trial of 24 children found cough drops containing ivy leaf extract to be significantly superior to placebo in reducing airway resistance.37 Despite this finding, the authors’ conclusion that larger placebo-controlled trials are needed remains.
On the basis of data available to date, it is not possible to make firm judgements about the effectiveness of the above CAMs in the treatment of asthma in children. However, we agree with Lewith38 that lack of evidence does not imply that treatment is not effective, but rather that effectiveness has not been adequately investigated.
