REVIEW

Minority mothers’ healthcare beliefs, commonly used alternative healthcare practices, and potential complications for infants and children Jean Hannan, PhD, ARNP (Assistant Professor) Nicole Wertheim College of Nursing and Health Sciences, Florida International University, University Park, Miami, Florida

Keywords Minority; complementary and alternative medicine (CAM); culture; ethnic; infants; lead poisoning; low income. Correspondence Jean Hannan, PhD, ARNP, AHC3 Room 324A, 11200 S.W. 8 Street, Miami, FL 33199. Tel: 305-348-0227; Fax: 305-348-7765; E-mail: jhann001@fiu.edu Received: 23 June 2012; accepted: 31 January 2013 doi: 10.1002/2327-6924.12153

Abstract Purpose: Complementary and alternative healthcare practices have increased substantially in the United States especially with low-income ethnic minority mothers. These mothers often have provider mistrust, language barriers, differing health belief systems, and as a result are less likely to seek preventive health screening, access healthcare services, and use alternative remedies for their infants and children that are potentially harmful or lethal. Therefore, the purpose of this article is to examine healthcare beliefs, commonly used alternative healthcare practices, and their potential complications for infants and children. Data sources: A search of CINAHL and PubMed (1980–2012) was conducted using the following terms: alternative healthcare practice, mothers’ health beliefs, cultural health beliefs, folk remedies, and infant health practices. Conclusion: Given the changing U.S. population and an increasing immigrant population, examining alternative healthcare practices mothers use for their infants and children is especially important for providers in addressing healthcare for this group. Implications for practice: The use of alternative healthcare practices is rarely discussed by parents with healthcare providers for fear of disapproval. When interviewing ethnic minority mothers and caregivers questions should include the use of alternative healthcare practices for infants and children and information regarding the potential dangers should be provided to them.

Introduction Complementary and alternative healthcare practices (also referred to as complementary alternative healthcare medicine) increased substantially in the United States during 1990 and 2002, especially in high-risk groups including ethnic minority mothers, most of whom were low income (Smitherman, Janisse, & Mathur, 2005; Su & Li, 2011). In addition, nearly 12% of children and teens in the United States receive or use alternative healthcare practices or treatment (Barnes, Bloom, & Nahin, 2008). Most alternative healthcare practices that include herbal medicines have not been trialed in clinical studies (Woolf, 2003). As a result, knowledge concerning how infants and children are affected by using alternative healthcare practices is very limited. Increasing our knowledge in this area becomes especially important because one of the high-risk groups, low-income ethnic minority mothers, is growing

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in numbers in the United States. Use of alternative healthcare practices in this group can adversely affect the health of mothers, infants, and children. The purpose of this article is to examine healthcare beliefs, commonly used alternative healthcare practices, and their potential complications for infants and children.

Mistrust and language Historically, use of alternative healthcare practices, common in all socioeconomic groups, has been attributed to cultural health beliefs. However, its increased use has been found in groups with a lack of access to healthcare, language barriers, low socioeconomic status, or groups with a mistrust of the healthcare system (Chao, Wade, Kronenberg, Kalmuss, & Cushman, 2006; Mendoza, 2009; Su & Li, 2011). Mothers with mistrust have fears that healthcare organizations deceive

Journal of the American Association of Nurse Practitioners 27 (2015) 338–348  C 2014 American Association of Nurse Practitioners

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or mislead patients, breach patient confidentially, and or expose them to harmful experiments (Williams, 2009). Several studies have documented that minority women with mistrust do not receive the recommended routine healthcare screenings (breast screenings, Pap smears), do not adhere to prescribed medical treatments (LaVeist, Isaac, & Williams, 2009; Moseley, Freed, Bullard, & Goold, 2007; Nguyen et al., 2009; Williams, 2009), have difficulty accessing the healthcare system for guidance for themselves and their infant (Campbell-Grossman, Hudson, Keating-Lefler, Yank, & Obafunwa, 2009). Others have documented that these mothers do not receive any healthcare guidance from healthcare providers (Rodr´ıguez, Bustamante, & Ang, 2009), have lower patient and provider satisfaction and unfavorable health outcomes (Graves et al., 2009; Halbert, Armstrong, Gandy, & Shaker, 2006). These minority women also experience discrimination by healthcare providers because of a lack of health insurance for themselves or their children (Sheppard, Zambrana, & O’Malle, 2004). A large amount of minority children (66%) eligible for Children’s Health Insurance Program (CHIP) or Medicaid are often not enrolled despite their children’s eligibility for fear of deportation (American College of Physicians [ACP, 2011]; Kaiser Family Foundation, 2009; Urban Institute, 2005). Approximately 55 million people in the United States speak a language other than English at home, and this number is increasing (Shin & Kominski, 2010). Language barriers cause misinterpretation of crucial information, resulting in poor healthcare outcomes (Andrulis, Goodman, & Pryor, 2002; Cheng, Chen, & Cunningham, 2007), dissatisfaction with care, serious medical complications, medical errors, longer hospital stays (Divi, Koss, Schmaltz, & Loeb, 2007), compromised care, and mistrust in healthcare providers especially for low-income individuals (Sheppard et al., 2004). Low-income ethnic minority mothers with language barriers face challenges in receiving appropriate healthcare for themselves and their infant because of a tremendous amount of misinterpretation of information. Many healthcare settings have inadequate interpreter services for people with limited English proficiency (Chen, Youdelman, & Brooks, 2007; Ginde, Clark, & Camargo, 2009; Ramirez, Engel, & Tang, 2008) despite federal and state laws requiring healthcare providers and hospitals receiving federal funds to provide access to such services (Chen et al., 2007). Healthcare providers often call upon untrained staff or untrained ad hoc interpreters, including family members and children. Untrained interpreters are susceptible to editing translated information to their own interpretation by omitting, adding, or substituting information, and are also susceptible to volunteered opinions and breaches of confidentiality (Chen

et al., 2007; Flores et al., 2003), resulting in less satisfaction with patient–provider relationships (Ramirez et al., 2008). A study examining bilingual medical staff who also interpret found that approximately one third of uncomplicated and two thirds of complicated medical cases resulted in interpreting errors (Elderkin-Thompson, Silver, & Waitzkin, 2001). Ramirez et al. (2008) found that when information is misunderstood, costly and unnecessary procedures may be ordered and necessary procedures may not be indicated and these patients receive less explanation and follow-up.

Health belief systems Health belief systems, a major reason for use of alternative healthcare practices, are influenced by culture, social background, experience of health and illness, and knowledge of health promotion that plays a vital role in determining preventive health behaviors (Hjelm, Bard, Berntorp, & Apelqvist, 2009). One of the factors that influence how low-income ethnic minority and immigrant mothers access healthcare includes conflicting belief systems (Choudhry, 2001; Lasser, Himmelstein, & Woolhandler, 2006). Health beliefs that are in conflict with those of the healthcare providers can affect the delivery of healthcare by competing treatment plans and a lack of trust in the healthcare system (Diette & Rand, 2007). These belief systems passed down through generations are often the most resistant to change (Grewal, Bhagat, & Balneaves, 2008). They prevent mothers from asking for professional advice (Bunik et al., 2006), resulting in low adherence to medically prescribed therapies (Gaetti, Jacobson, Gazmararian, Schmotzer, & Kripalani, 2009; George, Munro, McCaig, & Stewart, 2006), and denial of an illness (Waite & Killian, 2008). However, acculturation also has an effect on their belief systems. Immigrant and minority mothers may have belief systems that are unique to their culture and other beliefs that are from outside their culture (Chia & Costigan, 2006; Drife, 2005; Lai & Chau, 2007). For example, immigrant mothers from countries where breastfeeding rates are high may decrease breastfeeding in the new country (Bonuck, Freeman, & Trombley, 2005). Research findings indicate that as the time spent in the United States increases, breastfeeding decreases by 4% (Gibson-Davis & Brooks-Gunn, 2006). Bunik et al. (2008) reported that low-income Latina mothers exposed to postpartum stressors result in a low supply of breastmilk according to their health beliefs. Evaluation by a medical expert would not be sought for this problem. According to Davies-Adetugbo (1997), Nigerians mothers believe that breastfeeding their infant exclusively is harmful because of suspicion that the breastmilk can get contaminated, poisoned, or bewitched. Prelacteal feedings of herbal teas and ritual fluids are 339

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supplemented from birth to promote health and normal development. These mothers discard the colostrum because it is their belief that it is “dirty” and also potentially dangerous for the infant. It is especially important that healthcare providers are aware of an individual’s health belief systems, especially minority groups that may vary in their expression of illness depending on their culture (Carrington, 2006). Examining health beliefs of minority mothers provides insight related to their expressions of illnesses, their willingness to seek treatment, and the use of medical therapies (Bunik et al., 2008; Gaetti et al., 2009; Waite & Killian, 2008). Limited knowledge of health belief systems and cultural barriers may keep low-income ethnic minority mothers from seeking healthcare (Schettino, Hernandez-Valero, Moquel, Hajeck, & Jones, 2006). However, it has been documented that when these mothers have easy access to healthcare they are more accepting of the beliefs and practice of their immigrated country compared to mothers with limited access to care (Moscardino, Nwobu, & Axia, 2006). Healthcare professionals can influence their adoption of needed healthcare practices by acquiring cultural assessment skills and questioning minority mothers’ health beliefs on infant care. By collecting culturally accurate information from the mothers and families, healthcare providers can address misguided practices by providing accurate information and formulating a mutually acceptable and culturally relevant treatment plan (Campinha-Bacote, 2011).

Alternate healthcare practices There is a variety of alternative healthcare practices reported in the literature used by mothers of Asian, Hispanic, African, and other descents. The majority of the reported literature has been with Hispanic mothers. Mothers using alternative healthcare practices consider them effective because these traditions have been passed from generation to generation and are deeply embedded in their culture (Grewal et al., 2008; Smitherman et al., 2005; see Tables 1–3). According to the American Association of Poison Control Center, and other researchers alternative healthcare practice use in infants include Bala Goli, a round, flat, black bean that is mixed with a home remedy prepared infant “gripe water,” and Kandu, a red powder used by the Asian Indian community to treat stomach ache among others (see Table 1). Others have documented an African product, “Titin powder,” for the promotion of babies’ health (Moscardino et al., 2006), and cool bathing or the use of isopropyl alcohol to treat fever (see Table 3). Caregivers believe that these remedies work by opening the pores in the skin, providing the body with strength, preventing blood chilling, and removing toxins 340

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in the body. Risser and Mazur (1995) documented home remedies used for common pediatric illnesses in the Hispanic population. Mal de ojo (evil eye), also common in other cultures, is believed to cause harm or misfortune for the person to whom it is directed for reasons of jealousy or dislike. Others include empacho (blocked intestine), mollera caida (fallen fontanelle), and susto (fright). The most common alternative healthcare practice for these illnesses included a combination of herbs and doctor prescribed medications. Teas were used mainly for colic, abdominal pain, and colds. Most mothers reported a belief in folk illnesses: 70% had experience with mal ojo, 64% with empacho, 52% with mollera caida, and 37% with susto; 20% had taken their children to curanderos (traditional healers) seeking treatment with folk illnesses. The investigators concluded that cultural healthcare beliefs were commonly upheld in this Hispanic population. Many patients combined cultural healthcare beliefs while also depending on their healthcare providers for care. Awareness and understanding of these practices are important for healthcare providers to discuss with their patients especially because it may affect compliance and conflict with other prescribed medical plan. Crocetti, Sabath, Cranmer, Gubser, and Dooley (2009) surveyed Spanish-speaking Hispanic parents whose children presented for healthcare at a hospital-based pediatric clinic. A total of 180 parents were interviewed about their alternative healthcare practice use when their child is ill. Most children, 3 years of age or below, were covered by Medicaid. Results indicated that in addition to antipyretic medicines and using sponging for fever, alternative healthcare practices were also used. The most common alternative healthcare practice was chamomile tea, boiled epazote leaves to treat fever, cough, upper respiratory tract infections (URIs), diarrhea, vomiting, and teething. These alternative healthcare practice medicines have also been reported by other researchers for similar uses (Harrison & Scarinci, 2007; Taveras et al., 2004). Other alternative healthcare practices documented by Crocetti et al. (2009) for treating fever include applying alcohol on the feet or other parts of the body; placing potato slices in axilla area; and onion, salt, and liquor on their feet. The majority of parents reported they would sponge with cool water or rubbing alcohol for temperatures less than 100.3°F. Mothers believed the cause of fever included cold air, pain, teething, sickness, immunizations, or food eaten by the mother. The investigators concluded that cultural health beliefs and practices influence parents about the treatment of common childhood illnesses. However, data documenting effectiveness for common illnesses are lacking. Bearison, Minian, and Granowetter (2002) interviewed Hispanic mothers to investigate their health beliefs

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Table 1 Asian and Polynesian: Common mother and infant culture remedies Health Concern Indian Pneumonia (Saini, Gaur, Saini, & Lal, 1992) Stomach ache (Miller, Lerner, Schiamberg, & Anderson, 2003) Nourishment drink (NYC DoH, 2012) Cough Dry skin Parasites (NYC DoH, 2012) Teething Milk intolerance, colic (NYC DoH, 2012) Growth of children, Teething Cough, fever, diarrhea (NYC DoH, 2012) Rash, high fever (NYC DoH, 2012) Middle Eastern Teething powder (NYC DoH, 2012) Teething powder (NYC DoH, 2012) Teething powder (NYC DoH, 2012) Fussiness, irritability (Fernando, Healy, Aslam, Davis, & Hussein, 1981) Umbilical skin infection (Miller et al., 2003) Malaysian Cold cough (Ariff & Beng, 2006) Fever (Ariff & Beng, 2006) Mumps (Ariff & Beng, 2006)

Cambodian Protection—evil spirits (CDC, 2011) Hmong Diarrhea (Jintrawet & Harrigan, 2003)

Cultural Remedy

Used by

Cow’s urine concoction

Child

Bala Goli (a round flat black bean dissolved in “gripe water”) Kandu (mineral and herb red powder)

Child

Bala Guti (herbal) Bal Jivan (herbal) Balguti kesaria (herbal)

Infant Child Infant

Potential Health Complication

Severe poisoning, death (Adekile, Odebiyi, Ojewole, & Ogunye, 1983) Lead poisoning (NYC DoH, 2012) Lead poisoning (Saper et al., 2004) Mercury, lead, and arsenic poisoning (Saper et al., 2004)

Bal chamcha (herbal)

Infant

Lead poisoning (Saper et al., 2004)

Bala sogathi (Herbal)

Infant

Lead, mercury (Saper et al., 2004)

Pay-loo-ah (herbal)

Lead poisoning (NYC DoH, 2012)

Cebagin (herbal)

Infant

Farouk (herbal)

Infant

Santrinj (herbal)

Infant

Bokhoor (burning wood and lead sulfide to produce pleasant fumes)

Infant

Lead poisoning (Centers for Disease Control and Prevention [CDC], 1984) Lead poisoning (CDC, 1984) Lead poisoning (CDC, 1984) Lead poisoning (CDC, 1984)

Kohl (herbal) Surma (herbal)

Infant

Lead poisoning (CDC, 1984)

Inhalers to be avoided Wrap up in thick clothing Coining and cupping of the body Pinching the bridge of the nose A vinegar paste mixed with blue dye painted in the shape of a tiger over the parotid gland by someone born in the year of the tiger

Child Child

Respiratory distress Febrile seizure Bruising

Child

Skin irritation

Amulet (necklace with lead pendant) Child sucks on pendant

Infant Child

Lead poisoning (CDC, 2011)

Dried rhinoceros or cow gallbladder added to drinking water Rhinoceros feces rubbed on abdomen

Child

Nausea, diarrhea

Continued

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Table 1 (Continued) Health Concern Chinese Increase breastmilk

Colic (Alexandrovich, Rakovitskaya, Kolmo, Sidorova, & Shushunov, 2003)

c

Used by

Star anise; fennel seed (Akaa Foeniculum vulgare)

Mother

Fennel seed (a Aka F. vulgare)

Infant

Acute bronchiolitis

Shuang Huang Lian

(Kong et al., 1993) Hyperactivity Nightmares, Colic (cheng et al., 1998) Pneumonia, bronchitis (NYC DoH, 2012) Pain (Nelson, 1995)

(Chinese herbal inhalation) Ba Bow sen herb (ingested)

Polynesian Teething (Winters & Swartz, 2000) a

Cultural Remedy

Infants

Zi Jin Ding (herb)

Infants Child Child

Jama (herb; adulterated with phenylbutazone)

Child

Kava root (a Aka Piper methysticum)

Infant

Potential Health Complication

Infant seizure neurotoxicity (Dog, 2009; Ize-Ludlow et al., 2004) Premature thelarchy Infant neurotoxicity Hypoglycemia (Low Dog, 2009; Rosti, Nardini, Bettinelli, & Rosti, 1994; Turkyilmaz, Karabulut, Sonmez, & Can Basaklar, 2008) Pulmonary toxicity, allergic reactions, GIc upset (Han et al., 2011; Wang et al., 2010) Lead poisoning (CDC, 1984) Mercury poising (NYC DoH, 2012) Aplastic anemia (Doshi et al., 2009)

Hepatic disease (US FDA, 2002)

Aka, also known as. GI, gastrointestinal.

about asthma and asthma regimens to determine how alternative healthcare beliefs affected compliance with medically prescribed treatment plans. Most mothers did not use the medically prescribed asthma inhalers for the prevention of an asthmatic episode. Their beliefs about asthma prevention were based on alternative healthcare practices. Most mothers believed that an asthma attack was because of exposure to the cold and attributed their child’s asthma attack to the school teachers who allowed the child to go outdoors in the cold weather. They substituted use of alternative healthcare practices (Zumos) for asthma prevention (e.g., cod liver, onion, oil, honey, whale oil, garlic). Mothers’ apprehension to use medically prescribed asthma medications were based on mistrust with healthcare providers fully disclosing the side effects of asthma medications. Most mothers (60%) believed that their child did not have asthma when symptoms were not present. Eighty-eight percent believed that medications are overprescribed in the United States and that healthcare providers did not disclose important information to them. Mothers’ reliance on alternative healthcare practices for asthma prevention results in a high rate of noncompliance. The mothers also reported that they do not discuss their beliefs about alternative healthcare practices and their suspicion of medically prescribed medications with 342

their healthcare providers. Yet, these mothers believe they are compliant with an effective treatment plan that is in conflict with medically prescribed plans. Additionally, attempts to educate and increase a mother’s knowledge of asthma treatments were not successful. Study findings suggest that healthcare providers need to assess mothers’ health beliefs and alternative healthcare practices. Realistic assessment of mothers and families’ knowledge, understanding of the medically prescribed plan, and their belief in its adherence depends on the development of a trusting and accepting relationship between the mother and family and the healthcare provider (Martin, Williams, Haskard, & DiMatteo, 2005). Healthcare providers can gain knowledge about mothers’ and families’ cultural beliefs, attitudes, and subjective norms that are vital for adherence to treatment regimens. Further studies should investigate methods of improving the healthcare providers’ patient communication in order to coordinate medical and alternative health beliefs in efforts to increase patient compliance. Smitherman et al. (2005) in a qualitative study examined alternative healthcare practice use for treating fevers, teething, and colic among AfricanAmerican children less than 2 years of age in a Midwestern urban community. The majority of the 107 families enrolled, most being mothers, were of lower socioeconomic

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Table 2 Hispanic: Common mother and infant culture remedies Health Concern Country not disclosed Fever (Risser & Mazur, 1999) Colic Increase breastmilk, cough (Agrisources, 2008) Cough, bronchitis (Toxline and Toxnet, Toxicology Data Network, National Library of Medicine, 2012) Asthma, colds (Gardiner & Kemper, 2000) Constipation Cough, congestion (Pachter, Cloutier, & Bernstein, 1995) Fever colds Diarrhea, vomiting, colic, teething (Harrison & Scarinci, 2007; Tavares, Duroussea, & Flores, 2004) Fever, cough, diarrhea, vomiting, parasites, teething (Harrison & Scarinci, 2007; Tavares et al., 2004) Cough, bronchitis, ear infection (Young, 2007) Diarrea Intestinal parasites (Gonzalez-Coloma et al., 2012) Vomiting (Mabey, 1988)

a

Cultural Remedy Rubbing alcohol Star anise (Akaa anis estrella, Illicium verum) Eucalyptus (Aka* vapor rub, camphor)

Used by Child Mother Infant

Potential Health Complication Systemic absorption Intoxication (Risser & Mazur, 1999) Infant seizure (Ize-Ludlow et al., 2004)

Child

Death, seizure (Gardiner & Kemper, 2000)

Aloe vera gel ingestion

Child

Nausea diarrhea (Uddin, 2011)

Honey syrup (almond oil, castor oil, honey, wild cherry, licorice, and cocillana) Chamomile tea

Infant Child Infant Child

Risk of contamination with Clostridium Botulism spores causing botulism (Peirce, 1999) Vomiting, allergic reaction (Blumenthal, 2003)

Infant

Vomiting, sleepiness, weakness,

Child

Convulsions, respiratory, cardiac problems (Foster & Hobbs, 2002) Gastrointestinal irritation, nausea (Murray, 2002) Seizures, hallucination, possible death (Erdemir, 2010)

Boiled epazote leaves

Garlic

Child

Wormwood tea (Aka* Artemisia absinthium)

Child

Ginger

Child

Gastrointestinal irritation (Murray, 2002)

Aka, also known as.

status and receiving Medicaid. Findings indicated that alternative healthcare practice use for fever included cool bathing. Older caregivers (e.g., grandparents) were more prone to use isopropyl alcohol. Caregiver’s beliefs were that this alternative healthcare practice opened the pores in the skin, provided strength to the body, prevented blood chilling, and removed toxins from the body. Other alternative healthcare practices included catnip to treat infant colic, although this was used by only a small percentage. Older caregivers were more accustomed with alternative healthcare practice use and more prone to use the remedy of catnip tea. An additional alternative healthcare practice included Castoria, an over-the-counter (OTC) herbal laxative (contains Senna) used to relieve colic and constipation. The investigators concluded that the African-American families’ use of alternative healthcare practices was not because of limited access to medical care or financial struggles. Rather it is a tradition passed down through the generations as part of child rearing to maintain good health. Their use of alternative healthcare practices would be used even with sufficient access to

medical care. Therefore, it is important for healthcare providers to do a cultural assessment, including asking the types of home remedies used, when they are used, under what circumstances they are used, the reasons for their use, and how well they work. Based on this information, a discussion with the mothers or families can occur focusing on other treatments that can be used that would be more effective and have less harmful effects for the infant or child. Moscardino et al. (2006) determined that in circumstances where alternative healthcare practices are not available because of migration to another country, medically prescribed regimens become more acceptable to these mothers. Twenty-nine Nigerian mothers living in Italy with infants aged 2–12 months were interviewed regarding their alternative healthcare practice use and adherence to medically prescribed regimens for their infants. Mothers opposed but complied the pediatrician’s traditional views on childrearing. However, reasons for their compliance to the medically prescribed treatment plans were because of the difficulty in acquiring African 343

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Table 3 Other Hispanic, black, and European: Common mother and infant culture remedies Health Concern Dominican Republic Teething (Allen et al., 2000) Mexican Vomiting, colic, stomach pain (Gorospe & Gerstenberger, 2008) Teething (Klauber & McClung, 1984) European Colic, teething (Lusk, 2009; Zhang, Fein, & Fein, 2011) African American Constipation (Smitherman et al., 2005) Colic (Smitherman et al., 2005) Haitian Diarrhea (Kirkpatrick & Cobb, 1990) African Promotion of health (Moscardino et al., 2006) Seizure (Adekile et al., 1983) Jaundice (Schmid et al., 2006) Burns and wounds (Steenkamp, Stewart, van der Merwe, Zuckerman, & Crowther, 2001) a b

Cultural Remedy

Used by

Cordial de Monell

Infant

Potassium bromide poisoning, sedation, trouble breathing, death (Lee, 2009)

Greta Azarcon

Infant Child

Necklace made of rattle snake vertebrae

Child

Lead poisoning (Cabb, Gorospe, Rothweiler, & Gerstenberger, 2008; CDC, 2002) None

(Potassium bromide, betula oil, anise oil)

Belladonna tablets

Potential Health Complication

Stevens-Johnson syndrome, death (Lusk, 2009)

Sennas (Akaa Cassia senna and Alexandrian senna)

Infant

Catnip (Akaa Nepeta cataria)

Infant

Orange, guayaba, and lemon leaves (discontinue breastfeeding)

Child

Dehydration, malnutrition (Kirkpatrick & Cobb, 1990)

Titin powder

Infant

Not documented

Cow’s urine concoction

Child

Broom brush (Akaa Retama raetam) Senecio latifolius DC (Akaa Dan’s cabbage, groundsel, or ragwort)

Infant

Severe poisoning, death (Adekile et al., 1983) Respiratory failure, CNSb depression (Schmid et al., 2006) Pyrrolizidine alkaloids excreted in breastmilk causing liver disease (Roulet, Laurini, Rivier, & Calame, 1988)

Mother, Infant

Electrolyte imbalance, diarrhea, blisters, and skin sloughing. (Spiller et al., 2003; Wong, 2008) CNSb depression (Osterhoudt, Lee, Callahan, & Henretig, 1997)

Aka, also known as. CNS, central nervous system.

infant health remedies (e.g., “Titin powder”), the possibility of being criticized by the pediatrician, and their inexperience as a mother. These mothers’ contact with their current healthcare system, along with easy access of the healthcare services for their infants, facilitated their acculturation while maintaining their cultural beliefs.

Potential complications Complications from alternative healthcare practice use according to the U.S. Food and Drug Administration (FDA) include aplastic anemia (herbs adulterated with phenylbutazone), hepatic disease (Kava root), hemolytic anemia (lead and arsenic ingestion), lead poising (hemolytic anemia, hypertension), and death among

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others (Steenkamp et al., 2001; U.S. FDA, 2002; see Table 1–3). One of the major health complications from alternative healthcare practices in children is lead poisoning and contamination with heavy metals, such as arsenic and mercury (Moore & Adler, 2000). Lead poisoning can cause an array of complications, such as lethargy, hemolytic anemia, confusion, seizures, coma, learning disabilities and convulsions, and in severe cases can lead to brain damage and death (Michael & Sztajnkrycer, 2004). Significant amounts of lead have been reported as a contaminant or an intentional adulterant in some herbs and ethnic alternative health practices, such as the use of Ayurvedic medicine—an ancient Indian system of healing that uses spices, herbs, vitamins, proteins, minerals, and metals (e.g., mercury, lead, iron, zinc; Saper et al., 2004).

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Severe lead poisoning has been diagnosed in a preterm infant born to a 24-year-old Indian woman who had used lead- and mercury-contaminated medicinal tablets before and during her pregnancy (Tait, Vora, James, Fitzgerald, & Pester, 2002). Lead poisoning also has been associated with Hispanic alternative healthcare practices such as ‘‘litargirio,’’ a peach-colored powder that can contain up to 79% lead (Woolf, Goldman, & Bellinger, 2007). The most common alternative healthcare practices that contain lead are Greta and Azarcon (Table 2). These yellow to orange powders that contain as much as 90% lead are traditional Hispanic remedies used for symptoms of “empacho” or colic, stomach upset, vomiting, or constipation. They contain as much as 90% lead (Gerr et al., 2002). Infants and young children may be harmfully affected from alternative healthcare practices, such as ingested herbs and dietary supplements. There are reported cases of infants presenting with vomiting, myoclonic movements, and seizures after ingestion of star anise tea. Such teas are sometimes given in various cultures for the treatment of infant colic (Ize-Ludlow et al., 2004; Perret, Tabin, Marcoz, Llor, & Cheseaux, 2011). The FDA issued an advisory warning against the drinking of teas brewed from star anise because of reported illness in 40 individuals that included 15 infants (U.S. FDA, 2003). There are plants that can cause contact dermatitis, while others can cause allergic reactions, such as wheezing, rhinitis, conjunctivitis, and/or itchy throat (Woolf, 2003). It has been reported that chamomile can produce severe allergic reactions (e.g., anaphylaxis) in persons who are allergic to plants of the Compositae family (i.e., ragweed, chrysanthemum, and chamomile; Moore & Adler, 2000; Woolf, 2003). Alternative healthcare practices may affect lactation in breastfeeding women. Many herbs have lipophilic (fat soluble) properties and are expressed in the breastmilk, exposing the infant to the effects of the herbs (Woolf, 2003). This is especially concerning considering there has been little scientific study in the effects of herbs in infants (Woolf, 2003). Another, potentially harmful alternative health supplement is the Kava root. This commonly used herbal supplement sold in the United States has been reported along with a warning issued by the FDA (2002) that the Kava root can cause liver damage. Schmid et al. (2006) reported a 7-day-old infant who presented to the emergency room of a universityaffiliated hospital with respiratory distress and central nervous system depression. After interviewing the parents, it was determined that a tea made from a broom bush (Retama raetam) plant was given to the infant as an alternative health remedy to treat neonatal jaundice. Broom bush is a commonly used alternative healthcare practice for the treatment of neonatal jaundice in North African communities.

Gaps in the literature exist on the outcomes of alternative healthcare practices and their regulation. Regulations for alternative health supplements do not have the same strict regulations that prescription and OTC medications have to abide by. The Dietary Supplement Health and Education Act (DSHEA) of 1994 applies to prescribed medications and it does not apply to herbal and or alternative health medicines. Therefore, manufacturers do not have to establish the safety and effectiveness of an alternative health supplement before being sold to the public (National Institute of Health Office of Dietary Supplements, 2011).

Implications for nursing Differences in mothers’ health beliefs affect their attitudes about medical care and their ability to understand, manage, and cope with an illness. Therefore, healthcare providers must be knowledgeable about minority mothers’ alternative healthcare practices for their infants and children and the potential harmful complications. By obtaining accurate information from the mothers or parents by questioning the use of alternative healthcare practices (the types of home remedies used, when they are used, under what circumstances they are used, the reasons for their use, and how well they work), using a nonjudgmental approach is crucial in preventing conflicting regimens and promoting adherence to treatment plans. Insufficient information about alternative remedies use by parents for their infant or child can result in an inaccurate approach to diagnosis and management, prolong a hospital stay, and result in potential harm or death (Woolf, 2003). Communicating openly and effectively with families about recommended treatment plans that are safe, and culturally acceptable is central in preventing adverse outcomes (Smitherson et al., 2005).

Conclusion In summary, the use of alternative healthcare practices is rarely discussed by parents with healthcare providers for concern of being wrongfully judged, misunderstood, or that this information would provoke an investigation from the Department of Social Services (Jean & Cyr, 2007). Healthcare providers experience the effects of harmful alternative healthcare practices most often when a child is treated in the emergency department with a complication from their use (Pachter et al., 1995). Therefore, alternative healthcare use and practices should be discussed with the parents and caregivers in addition to the dangerous effects they can have on infants and children. It is imperative that healthcare providers develop an understanding of the purpose of alternative healthcare practices use in order to 345

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assist individuals in making informed and safe decisions. Given the frequent use of various alternative healthcare practice therapies, providers should inquire about alternative healthcare practice use in all children at each office visit (Jean & Cyr, 2007).

Acknowledgment This study was supported by the Florida Nurses Foundation.

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Minority mothers' healthcare beliefs, commonly used alternative healthcare practices, and potential complications for infants and children.

Complementary and alternative healthcare practices have increased substantially in the United States especially with low-income ethnic minority mother...
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