Complementary Therapies in Medicine (2013) 21S, S61—S69

Available online at www.sciencedirect.com

journal homepage: www.elsevierhealth.com/journals/ctim

Use of complementary and alternative medicine in

healthy children and children with chronic medical
conditions in Germany
Sven Gottschling a,∗, Benjamin Gronwald a, Sarah Schmitt b,
Christine Schmitt b, Alfred Längler c, Eberhard Leidig d, Sascha Meyer e,
Annette Baan e, M. Ghiath Shamdeen d, Jens Berrang c, Norbert Graf e

a
Center for Palliative Care and Pediatric Pain Medicine, Saarland University, Kirrbergerstr., 66421 Homburg, Germany
b
Saarland University, Medical Faculty, Germany
c
Gemeinschaftskrankenhaus Herdecke, Department of Pediatrics, Herdecke, Germany
d
Rehabilitationsklinik Katharinenhöhe, Schönwald, Germany
e
University Children’s Hospital, Saarland University, Homburg, Germany
Available online 8 July 2011

KEYWORDS Summary
Objectives: Use of complementary and alternative medicine (CAM) in children is common and
CAM;
probably increasing. However little is known about differences between healthy and chronically
Pediatrics
ill children with a focus on prevalence, reasons for use/non-use, costs, adverse effects and
socio-demographic factors.
Design: A questionnaire-based survey with 500 participants visiting the outpatient clinic of the
University Children’s Hospital Homburg, Germany was conducted over a 4-week period in 2004.
Recruitment was stopped when 500 questionnaires were handed out in total.
Results: Of the 405 (81%) respondents (242 with chronic conditions, 163 healthy children inci-
dentally visiting the hospital for minor ailments) 229 (57%) reported lifetime CAM use (59%
with chronic conditions versus 53% healthy children). Among CAM users the most prevalent
therapies were homeopathy (25%), herbal remedies (8%), anthroposophic medicine (7%), vita-
min preparations (6%) and acupuncture (5%). The main reasons for use were to strengthen
the immune system, physical stabilisation and to increase healing chances/maintain health.
Socio-demographic factors associated with CAM use were tertiary education (mother: p = 0.017;
father: p > 0.001), higher family income (p = 0.001) and being Protestant (p = 0.01). Expectations
towards CAM were high and most parents would recommend certain CAM (94%). 79% of the
users informed a physician about CAM use. Side effects were rarely reported (4%), minor and
self-limiting.

∗ Corresponding author. Tel.: +49 6841/16 28510; fax: +49 6841/16 28519.
E-mail addresses: kisgot@uniklinikum-saarland.de, sven.gottschling@uks.eu (S. Gottschling).

0965-2299/$ — see front matter © 2011 Elsevier Ltd. All rights reserved.
doi:10.1016/j.ctim.2011.06.001
S62
Conclusions: Clinical care and the physician-patient relation would benefit from an enhanced
understanding of CAM and a greater candidness towards the parental needs. The safety and
efficacy especially of CAM with high prevalence rates should be determined in rigorous basic and
clinical researches.
© 2011 Elsevier Ltd. All rights reserved.
Introduction
Background
An increasing and generally high prevalence of comple-
mentary and alternative medicine (CAM) use has been
documented in industrialised countries in children and
adolescents with chronic illnesses.1,2 Nevertheless determi-
nation of CAM use in pediatric populations is impeded by
differences in definitions of CAM, methodology of the dif-
ferent studies, differences in the sociocultural background
of the participants and small sample sizes of the investigated
populations.3—5
Definition
CAM refers to a broad range of healing philosophies,
approaches and therapies that exist largely outside the insti-
tutions where conventional medicine is taught and provided.
There is a considerable uncertainty about what exactly
constitutes CAM and what types of treatment should be
summarized under this term. The Cochrane Collaboration
defines CAM as ‘‘a broad domain of healing resources that
encompasses all health systems, modalities, practices and
their accompanying theories and beliefs, other than those
intrinsic to the politically dominant health system of a par-
ticular society or culture in a given historical period’’.6 CAM
is defined by the National Center of Complementary and
Alternative Medicine (NCCAM) as ‘‘a group of diverse med-
ical and health care systems, practices and products that
are presently not considered to be part of conventional
medicine’’.6
Prevalence studies
While there are compelling data concerning an increasing
CAM use in adults,7 the use of CAM by children not only is
less well studied, but also appears to have a considerable
prevalence.1,3,8 CAM use by hospitalised children as well as
in outpatient settings ranges from 1.8% to 84%.5,8—10 CAM
use prevalence rates are best studied in pediatric oncol-
ogy patients varying from 8.7% to 84%.10,11 A recent trial
showed prevalence rates between 36% in general pediatrics
and 61.9% in children with epilepsy.12
Methodological limitations of published studies
Most studies are neither population-based nor at least
almost representative (e.g. all children addressing a full-
service hospital) but focus on populations with specific
diseases like cancer.10,11 To our best knowledge there are
only 3 studies comparing prevalence rates of CAM use
in general pediatrics and children with chronic diseases.
S. Gottschling et al.
One study revealed a three times higher rate of CAM use
in children with chronic conditions4 while another trial
reported the highest user rate in the group of healthy
children.13 With an overall low falling number of those
both trials the informative value is limited. The third
trial included 281 respondents with highest CAM user rates
among children with epilepsy, cancer, asthma and sickle cell
disease.12
Aims
To assess the prevalence and types of CAM therapies used
as well as reasons for and against CAM utilisation in pedi-
atric patients with different conditions. Moreover, we were
interested in socio-demographic factors having influence
on CAM use, costs, perceived usefulness of the applied
CAM, side effects and whether CAM use is discussed with
physicians.
Methods
The survey was done in accordance with the institutional
review board of the Saarland University and the declara-
tion of Helsinki. We conducted a questionnaire-based survey
to examine the use of CAM in children and adolescents
in a tertiary university hospital in Germany with approx-
imately 10,000 outpatients and 6000 inpatients per year.
The survey was done during October 2004. Patients were
recruited in all specialised outpatient clinics of the Uni-
versity Children’s Hospital Homburg, Germany. ‘‘Healthy’’
children (no underlying chronic disease) were recruited dur-
ing admission for incidental injuries or minor diseases (e.g.
common cold). We explicitly asked for any chronic disease
and/or any permanent medication. If so, patients were allo-
cated to the chronic disease group. The questionnaire was
based on the questionnaire developed by Längler et al.
for their population-based survey on CAM use by pediatric
cancer patients in Germany.14 It consisted of 50 items eval-
uating the following factors: lifetime prevalence for CAM
use, reasons for/against use, expectations towards CAM,
financial expenditure including percentage of covering by
insurance, source of recommendation, percentage of par-
ents informing their physician about CAM utilisation, applied
CAM (a list of 69 CAM was provided together with the pos-
sibility of adding further CAM), observed adverse effects,
perception of helpfulness, percentage of recommendation
of CAM, sociodemographic aspects of users and non-users.
For this questionnaire we decided to exclude spiritual prac-
tices, prayer, exercise and nutritional changes because in
Germany those are considered common practice and would
have resulted in very high CAM user rates. Children address-
ing either the emergency department or the outpatient
clinics were eligible to participate. The only exclusion
Use of complementary and alternative medicine S63

Table 1 Lifetime prevalence of CAM use. Table 2 Reasons of non-users (155 participants responded)
for non-appliance (multiple entries possible).
Group CAM- Prevalence
user/total (%) Reason Total Prevalence
number number (%)

All respondents 229/405 56.5 Lacking information about CAM 64 41%

Chronic illness 143/242 59.1 Additional stress for the child 18 12%
Healthy 86/163 52.8 Fear of adverse events 9 6%
Cardiac disease 40/83 48.2 Additional costs 8 5%
Neurologic disease 34/54 63.0 Disadvice of the attending physician 8 5%
Respiratory/skin disease 32/46 69.6 Perceived ineffectiveness 3 2%
Miscellaneous chronic disease 37/59 62.7 Other reasons (not specified) 40 26%
Do not know 44 28%
Bold number indicate the highest percentage.

criterion was insufficient knowledge of German. All par-

ticipants received a questionnaire at the admission desk
and were asked to return it later duly completed into one
of the sealed boxes positioned in the waiting area of the
outpatient clinic. The questionnaires were filled in by the
patients’ caretakers (mostly the patients parents (moth-
ers)). The boxes were emptied later by persons not involved
in the patients’ treatment to assure anonymity.
Data were entered into an Access database (Microsoft).
Statistical analysis was performed using the Statistical Pack-
age for Social Sciences (SPSS 15.0., SPSS Inc., Chicago, IL).
Data are presented as mean (±SD). Means and standard
deviations were calculated for continuous variables. For
statistical comparison of continuous parameters, Student’s
t-test was employed. We used the Pearson chi-square test to
compare differences between various groups regarding the
use of CAM. A p-value <0.05 was considered significant.
Treatment categories according to the National
Institute of Health (NIH)
According to the NIH CAM categories we found the fol-
lowing rates (more than one method could be indicated):
biologically based practices 58%, energy medicine 21%,
manipulative and body-based practices 25%, mind-body
medicine 26%, whole medical systems 72%.
Expectations towards CAM
Expectations of users towards CAM were high with an over-
all percentage of 72% being confident or even absolutely
sure that CAM has beneficial effects for their children. Range
was from 66% (cardiac disease) up to 88% (respiratory/skin
disease).

Financial expenditure of CAM use

Results
76% of all users spent 500D or less on CAM. 4% spent more
500 questionnaires were allotted resulting in 405 analyzable
than 5000D on CAM. 43% in the group with a neurologic dis-
questionnaires (81%).
ease spent more than 500D compared to only 10% within
The participants consisted majorly of males (51.5%), with
the group of healthy children. 45% of all parents asked their
a mean age (SD) of 10.3 years (±5.3 years) and an age range
health insurance company for coverage which was granted
of 3 weeks to 24 years. The respondents were divided into
in 50% of the requests.
5 subgroups: Healthy, cardiac disease, neurologic disease,
respiratory/skin disease, and miscellaneous chronic disease.
Later patients with disturbance of growth, rheumatic, kid- Sources of recommendation
ney, liver, gastrointestinal, hematological, and metabolic
diseases were included. Table 1 outlines the lifetime preva- Parents received information about CAM mostly from their
lence of CAM use, with an overall prevalence of 56.5%. social environment and their attending physicians (Table 4).
The 176 non-users of CAM were asked to give reasons
for their decision not to use CAM. Reasons are detailed in How many users discussed their CAM use with a
Table 2. physician?
The main reason for non-use by patients with cardiac dis-
ease, as well as for patients with respiratory/skin disease 79% of all users informed a physician (not always the attend-
(43%) and healthy children (43%) was lack of information ing physician) about the CAM use of their child. The range
about CAM (36%). In patients with neurologic disease the was from 73% (miscellaneous chronic disease) to 85% (neu-
main reason for non-use was the suspected additional stress rologic disease).
for the child (30%). The reasons against CAM use in the group
with miscellaneous diseases were rather evenly distributed.
Additional costs, disadvice of physicians and perceived inef- How were the reactions of the physicians towards
fectiveness were rarely stated in all groups. The 229 users the communicated CAM use?
were asked for their reasons concerning CAM use. Table 3
details the reasons for CAM use of 229 users. Reactions are detailed in Table 5.
 S64
Table 3 Reasons for CAM use (multiple entries possible).

All Chronic Cardiac Neurologic Respiratory/skin Miscellaneous Healthy

disease disease disease disease

To strengthen the immune system 47% 47% 55% 82% 38% 38% 48%
Physical stabilisation 34% 39% 30% 41% 53% 38% 26%
To enhance the healing chances 25% 27% 25% 18% 38% 19% 22%
Relaxation 22% 20% 25% 24% 16% 14% 24%
Mental stabilisation 16% 17% 15% 29% 3% 19% 14%
Detoxification 5% 6% 5% 9% 6% 5% 2%
Other reasons 35% 28% 18% 26% 50% 32% 43%
Only 2% of the participants used CAM due to dissatisfaction with conventional medicine.
Bold number indicate the highest percentage.

Table 4 Sources of recommendation about CAM (multiple entries possible).

Sources of information All Chronic Cardiac Neurologic Respiratory/skin Miscellaneous Healthy

disease disease disease disease

Friends 32% 34% 33% 41% 32% 30% 30%

Person with related disease 19% 16% 18% 24% 13% 11% 23%
Heilpraktikera 18% 16% 18% 18% 23% 22% 21%
Media 23% 31% 20% 20% 22% 19% 29%
Family 21% 31% 20% 24% 25% 22% 24%
Attending physician 48% 49% 50% 62% 38% 32% 45%
Other physician 7% 8% 8% 15% 6% 5% —

S. Gottschling et al.
Other health professionals 9% 9% 5% 24% 3% 3% 9%
Other sources 9% 7% 8% 6% 9% 8% 8%
Bold number indicate the highest percentage.
a A Heilpraktiker in Germany is an alternative practitioner without medical school education.
Use of complementary and alternative medicine
Table 5 Reactions of the physicians towards communicated CAM use.
Group Affirmative
General practitioner 60.3%
Pediatric specialist in private practice 49.2%
Pediatric clinician 36.4%
Applied CAM
Only therapies with more than 2 users per group are listed.
Homeopathy is by far the most often used CAM (25%) fol-
lowed by phytotherapy (8%) and anthroposophic medicine
(7%). Patients with cardiac disease often used autogenic
training (15%) whereas acupuncture was the second most
commonly used CAM for respiratory/skin disease (19%).
Ranking of the different therapies related to disease groups
is detailed in Table 6.
Adverse effects
Adverse effects of CAM use were reported overall 9 times
(4%). All adverse effects were minor and self-limiting. Side
effects related to certain CAM were:
Homeopathy: 3 times primary aggravation of symptoms, 1
time mental alteration.
Phytotherapy: 2 times skin rash.
Mental healing: 1 time mental alteration.
Dietary restrictions: 1 time anorexia.
Urine therapy: 1 time primary aggravation of symptoms.
Recommendation of CAM
Parents were asked if they would recommend CAM use
to other persons being in a comparable situation. 94% of
CAM users would recommend certain CAM. Recommenda-
tion rates ranged from 90% (miscellaneous chronic disease)
to 97% (Cardiac disease and respiratory/skin disease).
Sociodemographic and financial aspects
Sociodemographic factor predicting CAM use was a main
focus of our trial. Parental age and number of siblings were
not found to play a major role concerning the decision to use
CAM. A higher monthly family income (>3000D ) was clearly
attributed with CAM use (p = 0.001), as well as tertiary edu-
cation of both mother (p = 0.017) and father (p < 0.001).
Other relevant sociodemographic factors are detailed in
Table 7.
Discussion
Prevalence
The use of CAM within various diseases in children has been
rarely investigated, especially compared to healthy chil-
dren. Our results with a lifetime prevalence of 56.5% of
all respondents are in a medium to upper range compared
with studies worldwide ranging from 1.8%5 to 84%10 lifetime
S65
Neutral Dismissive
37.0% 2.7%
43.7% 7.1%
45.4% 18.2%
prevalence. Our healthy patient subgroup used CAM nearly
to an equal extent than those with chronic conditions. This
is in contrast to a publication of McCann and Newell from the
UK who found prevalence rates of 12% among healthy chil-
dren compared to 40% for children with chronic diseases.4
Ang et al. reported about a 38% use of CAM in a group of well
children compared to 22% for children with HIV and 25% for
children with asthma.13 Post-White et al. found higher CAM
prevalence rates in children with chronic diseases (47% up
to 62% depending on the disease) compared to children in
general practice (36%).12 We could not identify other studies
explicitly comparing pediatric patients with chronic condi-
tions to healthy individuals.
Used CAM
Although a sample of 69 different CAMs was given with
an additional opportunity to add further therapies approxi-
mately 70% of all used CAMs were reflected by 10 different
CAMs. Homeopathy was in all subgroups and the most often
used CAM with overall 25%, although no replicated large-
scale trials with a rigorous design for any clinical disorder in
children are existing.15 Nevertheless parents and physicians
in primary care perceive homeopathic remedies as safe, nat-
ural and effective.15,16 Most often homeopathic remedies
were prescribed by Heilpraktikers and physicians, much less
was over the counter self medication. Other popular CAMs
in our survey were phytotherapy, anthroposophic medicine,
vitamin C and acupuncture. This range of popular CAM is in
line with other European studies on CAM use.14,17,18
Reasons for use/non-use
The main reason for use among all participants was to
strengthen the immune system followed by physical stabili-
sation and enhanced healing chances (27% of all participants
with chronic disease). The first two reasons are in line
with other publications3,14,20 whereas the percentage of an
expected enhancement of healing chances was remarkably
high, e.g. all patients with cardiac disease suffered from a
congenital cardiac defect and nevertheless attributed CAM
with a percentage of 25% for enhanced healing chances{AQ
for clarity}. The majority do not use CAM as a result of being
dissatisfied with conventional medicine, but it probably rep-
resents a parental need for additional treatment options
which appear to be potentially successful and innocuous.3,21
Reasons not to use CAM were mainly a lack of information
about CAM and a presumed additional stress for the child.
Assumed ineffectiveness of CAM was stated only by 2% of the
CAM non-users.
 S66
Table 6 Ranking of the different therapies related to disease groups (multiple entries possible) including percentage of users. Only therapies with at least 2 users per group
are reflected in this table. 21% of all users applied therapies not included in the questionnaire’s list of 69 different CAMs.

Ranking All Chronic Healthy Cardiac disease Neurologic Respiratory/skin Miscellaneous

disease disease disease

1. Homeopathy Homeopathy Homeopathy Homeopathy Homeopathy Homeopathy Homeopathy

25% 23% 28% 25% 26% 34% 27%
2. Phytotherapy Anthroposophic Phytotherapy Autogenic Phytotherapy Acupuncture Anthroposophic
8% medicine 8% 10% training 15% 15% 19% medicine 16%
3. Anthroposophic Phytotherapy Vitamin C Anthroposophic Anthroposophic Anthroposophic Phytotherapy
medicine 7% 7% 8% medicine 10% medicine 9% medicine 9% 11%
4. Vitamin C Acupuncture Anthroposophic Balneotherapy Balneotherapy Vitamin C 9% Acupuncture
6% 7% medicine 6% 10% 6% 11%
5. Acupuncture Autogenic Bach flowers Phytotherapy Vitamin C 6% Autogenic —
5% training 5% 6% 5% training 6%
6. Autogenic Vitamin C Autogenic Acupuncture 5% Autogenic Bach flowers 6% —
training 5% 4% training 5% training 6%
7. Bach flowers Balneotherapy Massage 5% Bach flowers 5% — — —
3% 3%
8. Balneotherapy Kinesiology Balneotherapy Massage 5% — — —
3% 3% 3%
9. Kinesiology Bach flowers Kinesiology — — — —
3% 2% 3%
10. Massage 3% Massage 2% Acupuncture — — — —
2%

S. Gottschling et al.
Use of complementary and alternative medicine
Table 7 Details of sociodemographic factors.
Patient characteristics
Age (years ± SD)
Gender (% male)
Compulsory (private) health insurancea (%)
Religionb (%)
Catholic
Protestant
Bold number indicate the highest percentage.
a Private health insurance in Germany is costly also reflecting higher socioeconomic status.
b Religion (223 Catholic, 141 Protestant, 41 miscellaneous (e.g. Muslim, Hindu, Buddhist, no religion, not stated)).
Socio-demographic factors
Age and gender were no significant predictors for CAM use
as well as parental age. Families being Protestant used CAM
significantly more often than families belonging to other
religious groups. We found no other trial explicitly focussing
on religious affiliation. One trial identified religiosity to be
a positive predictor for CAM use not further specified into
religious affiliations.19 CAM use was associated with parental
tertiary education, higher income and private health insur-
ance. This supports the findings of other studies that a higher
socioeconomic status is associated with CAM use.3,22,23
Costs
Financial expenditure in most cases was low to moderate,
also reflected by a low rate of non-users stating additional
costs as a reason for not using CAM (5%). 76% of all users
spent less than 500D for CAM. In the group of children
with neurologic disorders 43% spent more than 500D . This
might be explained by the tremendous burden families with
severely handicapped children often have, probably forc-
ing parents of children with reduced mobility to pay for
costly home visits of CAM practitioners. It is interesting that
less than 50% of the parents asked for insurance coverage
of CAM costs with an overall remarkably high number of
granted requests. Many parents are probably often not res-
olute enough to ask for coverage.
Disclosure
It is remarkable that 79% (even 85% with neurologic dis-
ease) of all users spoke to a physician about CAM use. This
is in contrast to the most published studies where the vast
majority of the users did not inform their physician.4,9,21,24
The attending physician was in our survey in 48% the source
of recommendation of CAM. Those figures are surprisingly
high and might reflect a possible change in the attitude
of conventional health professionals towards CAM at least
in Germany. Moreover there was an affirmative reaction in
60% of the general practitioners, whereas only 36% of the
pediatric clinicians reacted positively towards the commu-
nicated CAM use. We know from other studies that many
physicians feel that they know too little about CAM to pro-
vide substantial advice for their patients.3,23,25
S67
CAM-users Non-users p-Value
10.2 ± 5.1 10.4 ± 5.5 0.670
51.5 50.3 0.968
73 (27) 83 (17) 0.01
52 48 0.547
66 34 0.01
Perceptions and efficacy
A total of 72% of all users were confident that CAM had ben-
eficial effects for their children. This was also reflected by
a very high rate of recommendations to other persons in a
comparable situation. These perceptions towards CAM are in
line with other studies3,24,25 and might reflect the feeling of
being empowered to take greater personal control over the
child’s condition rather than to solely rely on conventional
medicine. CAM is often perceived as natural, individualised,
non-invasive and holistic; attributes rarely mentioned in the
context of conventional medicine.25 Even parents of healthy
children seek for alternative ways to maintain the highest
possible level of health for their child. In this regard it could
be particular dangerous that the vast majority perceive CAM
as natural and harmless. Most CAM users (77%) are confident
that interactions between CAM and conventional therapies
are excluded.26 Moreover many people (75%) believe that
CAMs are tested concerning quality and adverse effects and
are therefore safe.27
Safety
We explicitly asked for possible adverse effects of CAM
and further asked to specify them using a free-text field.
Although the reported rates of adverse effects were over-
all low, but comparable to other studies on CAM,3,20 it is
known that certain CAM could interact with conventional
medicine, leading even to fatalities.16 Especially interac-
tions between herbal remedies and prescription medications
are well documented.28,29 But even if CAMs with a doc-
umented low rate of adverse events are applied (e.g.
homeopathy), there is always the danger of delaying a
necessary conventional diagnostic process or treatment as
documented in trials on adult cancer patients.30
Limitations of this study
The study participants belonged to a pediatric popula-
tion recruited at one hospital including healthy children
and children with chronic illnesses. Approaching consec-
utive outpatients minimized the potential for sampling
bias. Nevertheless the results are not population-based,
but may apply to other tertiary pediatric centres with
comparable demographics. CAM use differs considerably
depending on the socio-cultural context. Therefore a com-
S68
parability of studies will always be difficult. Moreover the
definitions of CAM are not standardized making comparisons
between studies even catchier. It is for example controver-
sial whether prayer and spiritual healing is CAM or not. We
chose to offer a wide variety of CAM (69 items with an addi-
tional possibility of adding further CAM) to make sure that
we did not underestimate CAM use. The anonymous design
of the study was directed towards ensuring compliance and
reliable answers. Nevertheless 95 out of 500 issued ques-
tionnaires were not returned. Maybe an interviewer might
have raised the percentage of returned analyzable question-
naires.
Conclusions
In summary, CAM use is common among children in Germany
with comparable prevalence rates for healthy children and
children with chronic diseases. Pediatricians need to specifi-
cally ask about CAM in an open-minded and non-judgemental
way. Patients in particular should be aware of potential
interactions with conventional medicine. The high preva-
lence rates seem to represent the parental needs for
additional treatment perceived as successful and harmless.
Clinical care and the physician—patient relation would ben-
efit from an enhanced understanding of CAM and a greater
candidness towards the parental needs, even if CAM use does
not match with the conception of the world of many physi-
cians. The safety and efficacy especially of CAM with high
prevalence rates should be determined in rigorous basic and
clinical researches.
Conflict of interest
All authors state that no potential conflict of interest is
involved with this work.
Acknowledgements
The authors thank all the nurses and staff members of the
University Children’s Hospital Homburg for their support.
Parts of the study were supported by a Grant of the Elternini-
tiative krebskranker Kinder im Saarland e.V. We thank Karen
Schneider for linguistic help.
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