TUESDAY, AUGUST 20 , 2019. THE WASHINGTON POST EZ EE E5
colds. She still gives her sons
other supplements, including vi-
tamin D, melatonin and probiot-
ics, but “we do wonder if we are
wasting money,” she says.
Martin is one of a growing
number of parents who give herb-
al dietary supplements to their
children. Most aren’t designed or
marketed for kids: According to
Innova Market Insights, a mar-
keting research group of the food-
and-beverage industry, just under
5 percent of dietary supplement
launches target children. But sup-
plement use among children is
much higher.
About a third of children in the
United States use dietary supple-
ments, according to a nationally
representative survey of Ameri-
can children and adolescents. Be-
tween 2004 and 2014, partici-
pants’ use of herbal and nonvita-
min supplements nearly doubled,
from 3.7 percent to 6.7 percent in
2013-2014.
Fish oil, melatonin and probi-
otics are the most commonly used
dietary supplements outside vita-
mins.
Researchers still know little
about whether or how dietary
supplements can benefit — or
hurt — kids. Studies of herbal and
homeopathic remedies can have
design flaws, and products can
lack randomized clinical trials.
Parents often rely on anecdotal
evidence instead of reliable medi-
cal studies. And decisions to buy
and administer vitamins and oth-
er products can be swayed by
advertising or a parent’s own sup-
plement use.
According to a Centers for Dis-
ease Control and Prevention re-
port, children with parents who
use dietary supplements or other
complementary health approach-
es are more likely to use them
than kids whose parents do not.
“I am always very hesitant to
recommend any supplements to
patients, even when there is some
evidence of effectiveness,” saysSUPPLEMENTS FROM E1 pediatrician Natalie Muth, a
spokeswoman for the American
Academy of Pediatrics. “In many
cases, there is no evidence of
effectiveness.”
Nevertheless, kids’ use of herb-
al supplements continues to rise.
So do the number of calls to
poison centers. “[Supplement-re-
lated calls] have been steadily
increasing since 1994,” says Susan
Smolinske, director of the New
Mexico Poison and Drug Informa-
tion Center. That’s when legisla-
tion went into effect that allows
the Food and Drug Administra-
tion to intervene only after prod-
ucts are already on the market.
“What that created in this es-
sentially almost unregulated en-
vironment is an industry gone
wild,” says S. Bryn Austin, a public
health researcher and professorat the Harvard T.H. Chan School
of Public Health. “The industry
went from 4,000 products on the
market when this law was passed
to well over 80,000 products on
the market.”
Austin warns parents that just
because a product is on store
shelves doesn’t mean it’s safe for
children — or even that it con-
tains what it claims on the bottle.
The FDA has recalled 12 dietary
supplements in 2019 alone; most
of the recalls related to mislabel-
ing or undeclared ingredients.
Austin and other researchers
examined the FDA’s database of
unwanted side effects of supple-
ments in children and adoles-
cents, known as adverse events.
Of the 977 events reported be-
tween 2004 and 2015, about
40 percent involved severe medi-
cal outcomes such as hospitaliza-
tion, disability or death. Supple-
ments that promised energy,
weight loss and muscle buildingwere associated with nearly three
times the risk of an adverse event
than those that did not.
“The claims are not true,” Aus-
tin says. “These products are not
proven to turn anyone into an
Olympic athlete or the highest
scorer on their team. What they
are proven to do is lead to serious
adverse events when the products
have dangerous ingredients,
which too often they do. Parents
cannot look at the bottle or box
and read the label and know
what’s in there.”
In a study published in the
journal Hepatology Communica-
tions this year, researchers ana-
lyzed the ingredients of 272 herb-
al and dietary supplements asso-
ciated with liver injury. Fifty-one
percent of them had ingredients
that weren’t listed on the label.Todd Raymond and his daugh-
ter Abby, a 14-year-old team USA
weightlifter, learned about that
risk firsthand last year. After a
family friend with a supplement
company offered to make the ath-
lete an ambassador for his fit-
ness-related supplements, the
Raymonds scoured the ingredi-
ent list for substances that might
violate anti-doping rules. “Every-
thing looked good to go,” Todd
Raymond says. Abby began tak-
ing the supplements and promot-
ing the brand.
But during a random drug test,
she tested positive for ostarine, a
non-FDA-approved substance
that produces results similar to
anabolic steroids. She was sanc-
tioned by the U.S. Anti-Doping
Agency (USADA) and disqualified
from medals, points and prizes
she earned before the test.
“It was devastating,” Todd says.
After product testing, the Ray-
monds learned that the supple-ments Abby had consumed were
contaminated during produc-
tion.
Today, Abby is 15. She has re-
turned to competition, and the
Raymonds share their story with
other youth athletes through
TrueSport, the USADA’s educa-
tional program.
Jennifer Royer, USADA’s
TrueSport and athlete education
director, says that the organiza-
tion has recently seen a rise in
supplement use among younger
athletes.
“Because parents have access
to these products at their local
grocery store, they assume they’re
safe, but the supplement market
is unregulated and evidence sug-
gests that the modest regulation
in place does little to dissuade
companies from manufacturing
with ingredients that are prohib-
ited or dangerous,” she says.
Adolescents aren’t the only
group at risk. Thirty percent of
supplement-related emergency
room visits between 2004 and
2013 involved children age 10 or
younger. The majority were kids
who ingested the supplements
without parental supervision.
“You should be very vigilant
about keeping them out of reach
until it’s time to dispense them,”
Smolinske says. Child-resistant
packaging isn’t required for di-
etary supplements that don’t con-
tain iron.
Independent test providers
such as ConsumerLab.com and
certification programs such as
the one offered by NSF Interna-
tional, formerly called the Na-
tional Sanitation Foundation, can
help direct parents toward high-
er-quality products. “You should
look for trusted brands from
trusted companies,” says Andrea
Wong, vice president of scientific
and regulatory affairs for the
Council for Responsible Nutri-
tion, a trade association repre-
senting dietary supplement man-
ufacturers.
So how can a parent responsi-
bly navigate the slippery world ofsupplements? In written state-
ments, representatives from the
FDA and the National Institutes
of Health urged parents to com-
municate with their child’s pedia-
trician before giving their kids an
herbal remedy or other supple-
ment. NIH also offers a series of
tip sheets online, including one
with questions parents might
want to ask health-care provid-
ers.
Often, Muth says, parents don’t
realize a pediatrician might be
able to address their kids’ health
concerns in ways that don’t in-
volve supplements.
“If a pediatrician learns that a
parent is giving a child melatonin
as a last-ditch effort to help a
child sleep, it creates an opportu-
nity for the family and pediatri-
cian to troubleshoot why the
child may be struggling so much,”
she says. “Or, if a pediatrician
knows that parents are giving
their toddler a multivitamin be-
cause they are so concerned the
child will become malnourished
due to picky eating, it creates anopportunity to discuss strategies
to help increase a child’s willing-
ness to try new foods.”
In turn, the American Acad-
emy of Pediatrics recommends
that pediatricians ask patients
about which supplements kids
are taking.
Smolinske’s poison center han-
dles tens of thousands of calls a
year — and she has another rea-
son to second-guess supple-
ments: “Because of my experi-
ences, I worry that giving these
drugs to treat a disease may delay
a diagnosis or evaluation by a
physician. If [parents] decide to
go it on their own, they may be
ignoring something that should
be evaluated by a physician.”
During her career, Smolinske
has seen children with brain tu-
mors, severe anemia and other
life-threatening conditions go un-
treated because their parent
thought an herbal supplement
could cure their symptoms.
“They think that Dr. Google has
all the answers,” she says.
[email protected]kids health
BY CAREN CHESLERW
hen Joann Alfonzo, a
pediatrician in Free-
hold, N.J., walked into
her office recently she
mentally rolled her eyes when she
saw her next patient: a 26-year-
old car salesman in a suit and tie.
“That’s no longer a kid. That’s a
man,” she recalls thinking.
Yet, Alfonzo wasn’t that sur-
prised. In the past five years, she
has seen the age of her patients
rise, as more young adults remain
at home and, thanks to the Af-
fordable Care Act, on their par-
ents’ health insurance until age
26.
“First it was 21, then 23 and
now 26,” Alfonzo says. “A lot of
them can’t afford to live on their
own and get their own insurance,
or even afford the co-pay. And if
insurance is offered at work,
there’s generally a cost share in-
volved, if insurance is provided at
all.”
The idea of young adults con-
tinuing to see their longtime pe-
diatricians has been around for
quite some time — it was a laugh
line on “Friends” in its last TV
season in 2004. Rachel takes her
child to a pediatrician, she sees
the child’s father, Ross, in the
waiting room and realizes he’s
still a patient.
But these days that’s pretty
realistic, Alfonzo says. “We have
people who have had children,
and they still see us, so we’re
seeing the parents and their chil-
dren, concurrently,” she says.
So when is it time to leave your
pediatrician? Talon Manfredini,
22, says he only left his pediatri-
cian, who is a woman, this year
because he moved from his family
home in New Jersey to begin a
new job in Miami.
But he didn’t think twice about
continuing to see her, even
though he’d finished college. “She
just felt like a regular doctor,” he
says. “It didn’t feel odd at all or
different or weird or anything
like that.”
Debbie Weinberger DeFran-
cesco, 41, a regional sales manag-
er for Tyson from Marlboro, N.J.,
says she continued to see her
pediatrician until she was about
27.
“The thing I remember very
clearly, especially towards the
end of my time there, was how the
moms were the same age as me —
and not thinking that I was too
old for the doctor but that they
were too young be having babies,”
she says.
She finally decided it was time
to get an “adult” doctor when she
got married. “I thought it was a
good idea for my husband and me
to share the same doctor and
have our files under one roof,” she
says.
Aside from some potentially
awkward moments in the waiting
room, is there anything wrong
with pediatricians continuing to
treat their patients once they
become adults?
A little, Alfonzo says.
“We’re now treating people for
adult diseases, things we weren’t
trained to treat,” she says, such as
adult hypertension, Type 2 dia-
betes, high cholesterol, pregnan-
cy, even depression and anxiety. If
she encounters something she
can’t handle, Alfonzo says she will
refer the patient to a specialist.
“Actually, I think it impacts
them more in a positive manner,
because I think pediatricians are
very thorough in their assess-
ment,” she says.
It’s certainly more thorough
than an urgent care center, which
is where many 20- and 30-some-
things wind up when they don’t
have insurance and are no longer
seeing their pediatrician, Alfonzo
says.
The American Academy of Pe-
diatrics (AAP) attempted to ad-
dress the issue of transition from
pediatric care into adult care in a
policy statement in 2017 and con-
cluded “the age of transition”
should be based not on a number
but on the patient’s individual
needs.
The decision “should be made
solely by the patient (and family,
when appropriate) and the physi-
cian and must take into account
the physical and psychosocial
needs of the patient and the
abilities of the pediatric provider
to meet those needs,” the policy
statement said. In addition, it
said that ‘the establishment ofarbitrary age limits on pediatric
care by health care providers
should be discouraged. Health
care insurers and other payers
should not place limits that affect
the patient’s choice of care pro-
vider based solely on age.”
The statement was written and
published because more pediatri-cians were seeing older and older
patients, and because insurers
and health-care providers had
begun to draw arbitrary lines as
to the age at which a patient
should no longer be seen by a
pediatrician, said Jesse Hackell,
vice president of AAP’s New York
chapter and a co-author of the
statement.
“There are no official, legal
rules,” Hackell says. “Sometimes
the insurance companies will try
and make rules. Sometimes thehospitals will make rules. But
there’s nothing to say we couldn’t
keep seeing them. We’re licensed
as physicians, not pediatricians.”
Hackell, a pediatrician in
Pomona, N.Y., says he has patients
who definitely don’t want to
leave, and most of their problems
are ones he is equipped to dealwith. Often, he’ll keep the pa-
tients through their college years.
Why should they have to find a
new physician if they get sick
while they’re home on break? he
asks.
“I won’t take on a new patient
after about the age of 18 or 20, but
I will certainly see my patients
who I’ve seen since they were
kids,” he says.
Once they graduate, though, he
generally tells them it’s time to
start looking for a general practi-tioner who treats adults, he says.
“We have to gently nudge them
out,” he says.
Living at home and remaining
on parents’ insurance policies
aren’t the only reasons
20-somethings stay with pedia-
tricians. Medical advancements
over the past decade are extend-
ing the life expectancy of those
with chronic childhood illnesses,
such as congenital heart issues,
cystic fibrosis, hemophilia and
diabetes, and the pediatricians
who cared for children with these
conditions sometimes remain
with them as they get old, says
Michelle Hofmann, medical di-
rector in pediatric services at
NeuroRestorative in Riverton,
Utah.
Hofmann says when she was
training in a pediatric intensive
care unit, she had to resuscitate a
50-year-old man who was in her
children’s hospital because he’d
had congenital heart disease
since he was a child. When it was
time to do heart surgery, he want-
ed to have it there.
“One of the things that I think
they do really well in pediatrics is
establish those lifelong relation-
ships, because your visits are so
frequent when you’re growing up.
If you don’t move around a lot,
you do tend to stay with the same
doctor,” Hofmann says.
The care can also be different.
Her patients with cerebral palsy,
for instance, have neurological
issues from birth that may re-
quire supportive technologies
such as feeding tubes or ventila-
tors, technologies that when used
on adults are often not to prolong
life but rather in the face of a
traumatic accident or a life-end-
ing illness. And who would a
patient with cerebral palsy,
caused by brain damage that
occurred before birth or during a
child’s first three to five years,
see? Hofmann asks.
For those without major issues,
though — a college student or
graduate about to embark on
working life — the transition can
be abrupt, sometimes precipitat-
ed by a “Sorry, you’ve aged out”
response when they call to make
an appointment or by a sign in
the waiting room.
Debra Blau Reicher, a school
psychologist, says she continued
to consult her childhood pediatri-
cian about her health issues well
after she began taking her daugh-
ter to see him. If her daughter had
strep, the pediatrician would do a
throat culture on Reicher as well.
“He would see me in his wait-
ing room so he wouldn’t have to
charge me,” she said. “But thenone day he had a sign up,” she
recalls, saying “I can no longer see
parents.”
She was 30 when the sign was
posted.
There are better ways than
posting a sign for transitioning
patients who need to move on,
says Jonathan Trager, a pediatri-
cian in Great Neck, N.Y., whose
practice includes adolescent
medicine.
“Throughout the teen years
into the college years, you let your
patients know that you are happy
to see them as long as they are
comfortable,” says Trager, who
sees patients until age 30. When a
patient is ready to switch to an
internist, or is dealing with issues
that may require an internist,
Trager and the patient will make
that transition decision together,
he says. It should be a change that
they gear up for over the years, he
adds.
A pediatrician, Trager says, is
the ideal person to guide the
young patient through that tran-
sition into adult medical care.
“They know the patient,” he
says. “They know the family, and
they’re well equipped to handle
issues of someone they have been
seeing for a long time. Young
adults are often extended adoles-
cents. They still could benefit
from seeing the pediatrician who
knows them well.”
For older pediatric patients, it’s
not the doctor so much as the
waiting room, usually geared
toward toddlers and young pa-
tients, that starts to feel awkward.
“While the doctor may be
equipped to see them medically
and know them well, the patient
may feel out of place and doesn’t
want to come,” Trager says.
Jake Ambrosio, 21, is one of
those patients. He has been see-
ing his pediatrician since he was
born but has outgrown the office.
“There’s a lot of babies in the
waiting room, and also all of the
rooms have a theme. I’ll be get-
ting a checkup and there’ll be
like, the Candy Land room, this
light pink room with these little
candies all around, and I’m like,
‘Yeah, I think I’m ready to be in
just a normal doctor’s office.’ ”
So why has he stayed with his
pediatrician this long?
“I like her. And it’s a lot of work
finding a real doctor. It’s just
easier to stay,” he says. “But I
know I have to stop going to the
pediatrician eventually. I just feel
like since I’m 21, it’s time for me to
find an adult doctor. Even though
I do really like my pediatrician.
It’s part of growing up, I guess.”
[email protected]ILLUSTRATIONS BY ERY BURNS FOR THE WASHINGTON POST“She just felt like a regular doctor.”
Talon Manfredini, 22, who kept his pediatrician
until he moved out of town this yearJust because a product is on store shelves
doesn’t mean it’s safe for children.
The potential perils of herbal supplements
Why young adults keep their
pediatrician as their doctor