This study found that 455 (59%; 95% CI: 56-62) of 771 children and adolescents visiting a paediatric outpatient clinic had used CAM at least once. A Danish questionnaire study from 2003 (n=622), also performed at Hans Christian Andersen Children’s Hospital, found that 53% of the patients had used CAM . A German questionnaire-based survey from 2011 (n=405), found that 57% of the patients had used CAM . A systematic review from 2013 included 11 surveys (n=17.631) and demonstrated that the average prevalence of CAM use was 42% . The proportion in a similar Australian study from 2015 (n=883) was 44% . Thus, the various studies show that the proportion of CAM users varies over the years, but appears to be increasing over time, since the prevalence found in our study and recent literature is higher than ever.
The Danish study published in 2003 found that the most popular type of CAM was HM, secondly AT and finally CHI, only used by 14% of the patients . These frequencies are somewhat different now, where CHI is the most popular type of CAM used by 34%, secondly AT and thirdly HM.
Patients suffering from gastrointestinal diseases including infantile colic was the most frequent users of CAM, both within the last month and previous, with a total of 113 out of 141 patients (80%) (Table 4). The most popular type of CAM among these patients were CHI, with the majority being recommended CHI by their health visitor (46%). The latter is comparable to other studies , and may explain the great increase in use of CHI. A systematic review from 2019 investigated four high quality RCTs and found the effect of chiropractic on infantile colic to be inconclusive . Several studies indicate a positive effect. However, the studies are too small and methodologically prone to bias to draw reliable conclusions [14, 15].
Patients suffering from asthma, allergies and eczema were also frequent users of CAM, with a total of 139 out of 202 patients (69%) (Table 4). This is in accordance with previous studies [6, 16, 17]. They preferred HM, often to strengthen the immune system and not specifically to treat the disease. This pattern is recognized in cancer patients as well [4, 5].
The wish to strengthen the immune system was a frequent indication (Table 3), and the most popular type of herbal drug for this was Echinacea (28%), an extract of plant. A Cochrane review found no evidence to recommend Echinacea products for the treatment or prevention of the common cold . The most frequently used dietary supplement was lactic acid bacteria, including Lactobacillus reuteri, which is a well-studied probiotic bacterium, that has shown to be promising for colic in breastfed infants [19-21].
In agreement with previous studies, gender and age did not significantly influence the use of CAM [4, 5]. Some studies have demonstrated a lower use among small children [2, 3]. However, our results and those of others [4, 5] did not support this finding. On the contrary, it seems that children aged less than 5 years were the most likely to have used CAM, which may be explained by the frequent use against infantile colic.
Other reasons could be recall bias, an age effect (e.g. more likely to be ill and resort to CAM use), a time effect (e.g. CAM more popular in the last 5 years) or a combination [4, 22].
Several studies have shown that parents, who used CAM for their children were more skeptical about vaccines [23-25]. A qualitative study found that parents, who were vaccine opponents, embraced CAM as a protective strategy for the immune system, and that they preferred to discuss vaccine recommendations with their CAM provider instead of their medical doctor . This is comparable to our study, where the majority of patients who did not follow the vaccine program had used CAM at least once (75%) compared to the average usage of 59%. However, no significant association between following the Danish Childhood Vaccination Program and using CAM was found, which can be due to a small sample size of non-vaccinated children and therefore low statistical power.
The majority of patients reported a positive effect from CHI (74%) and AT (50%), while HM was considered the least effective treatment, with a reported positive effect of 33% (Table 2). It is remarkable that CHI and AT, which both involves a CAM provider, were considered to be more efficient compared with HM, where the patients often are the primary manager themselves.
Less than half of the patients, had discussed their use of CAM with their doctor [4, 6, 11]. This may be because the majority were never asked about CAM, and because of the patients being unaware of the importance of telling their doctor. A study from 2020 found, that the most common reason for the patients not wanting to tell their doctor about their CAM use, was that the doctors were not sufficiently informed about CAM . This is unfortunate, as CAM might have adverse effects caused by interaction between CAM and conventional medicine, a worsening of the present diagnosis because of cessation of conventional treatment and side-effects of CAM [27-29]. Side-effects caused by HM can be difficult to predict because of insufficient declaration of content. The Danish National Board of Health rarely receives reports about malpractice in relation to the use of CAM , which is consistent with our study where only 3% (12 out of 455 patients) reported negative side effects.
CAM was primarily used as a supplement for conventional medicine or for symptoms where medical treatment is not normally used, such as infantile colic or to strengthen the immune system (Table 2). 9% of the CAM users or 5% of the total pediatric patient population used CAM instead of medical treatment, which is in accordance with previous studies [4, 22]. Previous studies found that the majority does not use CAM as a result of being dissatisfied with conventional medicine [4, 8] but largely because CAM is more congruent with their own values , experience CAM as a more individual treatment , for colic where medical treatment has little to offer exhausted parents , or to offer hope when conventional medicine might have outplayed its role in very ill patients .
The participants were asked about their use of CAM within the last month and more than a month ago. Thus, it is possible that recall bias may occur and result in an underreporting of CAM use. Furthermore, it is possible that the parents have been reluctant to reveal the use of CAM. However, since the survey was voluntary and anonymous, the number of patients where this is the case is probably low, and therefore not considered to significantly influence the results of this study. Our results are based on data from self-administered questionnaires, which can result in a lower response rate and underestimated use compared to interviewer-administered questionnaires. However, the questionnaires were completed at the hospital and the interviewer was present at all times. Also, there is no widely accepted definition of CAM, and comparison with studies from other countries and between historical cohorts can therefore be difficult.
In conclusion, 59% of the patients had used CAM at least once, which is an increase compared to previous Danish and foreign studies. Most frequently used was CHI (34%), secondly AT (22%) and thirdly HM (17%). A positive effect was reported from 33-74%, although studies have lacked the scientific rigor to establish clear effects of CAM. However, the prevalence of CAM use is higher than ever before and pediatricians should therefore have sufficient knowledge about CAM and be prepared to provide guidance on this topic.