SUMMARY
It is the position of the National Association of School Nurses (NASN) that school districts need written policies and procedures that focus on student safety and are consistent with state laws, nursing practice standards, established safe practices, and scientific information. Requests to administer or permit a student to carry any substance for relief of a condition or symptom, or prevention of a health-related concern should be regarded as a medication request. The school nurse should assess each request for administration or student self-administration of herbal or alternative medicine based on school district medication administration policies.
NASN believes school district policies should not permit a school nurse or other staff to administer any product that could be considered a drug, including "natural remedies," herbs, vitamins, dietary supplements, homeopathic medicines, or medications from other countries, without
a written order from a health care provider authorized to prescribe in that state,
identification of the condition for which the product is being used,
a written request from the parent/guardian,
verification that the product and requested dosage are safe for the student (considering age, body weight, and condition), and
reasonable information about therapeutic and untoward effects and interactions.
Policies regarding administration or carrying of any medication or product should be applied consistently with all students. Policies should not prohibit parents/guardians from administering the product at school themselves. NASN recommends that an advisory council or committee, whose participants include a school nurse, local pediatric health care professionals, pharmacists, and people who are knowledgeable about current research on complementary and alternative medicines, assists in drafting policies that focus on student safety and scientific knowledge.
NASN believes the use of herbal and other alternative or complementary medicines represents a health teaching opportunity and responsibility for school nurses. Parents can be advised as to the safe use of complementary and alternative medicines, and should be encouraged to disclose any use to their child’s health care provider.
HISTORY
Alternative and complementary medicine includes products or practices not currently used, accepted, or available in conventional medicine. Alternative medicine is any practice that is available to the public but not integrated into standard medical practice. Complementary implies that the practice could be applied along with conventional medical care. These types of medications may be either herbal or homeopathic (NIH, n.d.).
Herbals (also called botanicals, dietary or nutritional supplements, or phytomedicinals) are products that can be purchased without a prescription. These products have not been regulated by the U.S. Food and Drug Administration (FDA) until recently. Current regulations apply only to product label information. Consumers may believe that a product marketed as "all natural" or "not a drug" is a treatment with no risk of side effects or is less costly than a prescription drug.
The Dietary Supplement and Health Education Acts (DSHEA) of 1997 and 1999 address "supplements," including herbs, vitamins, and minerals. DSHEA does not require proof of product safety, purity, or bioavailability of the active ingredients. Manufacturers’ labels may state effects on body functions but cannot make claims about treatment for any disease or condition. FDA approval is required for claims on treating a condition (Dockrell & Leever, 2000).
The USP (United States Pharmacopeia ) sets standards for product quality and label information by verifying that the declared ingredients are actually present in the product and by inspecting the manufacturing processes. However, the USP does not regulate claims made for product use. Manufacturers’ participation in USP review is voluntary. In addition to the product regulation issues, there are no standardized dosing guidelines, particularly for children’s safe use of herbal products.
Homeopathic medicine has been practiced since the nineteenth century and is integrated into conventional medical practice in many countries. It is an alternative medical system that uses extremely small amounts of biological, animal, or chemical substances to effect change in the body. Research results on the efficacy of homeopathy have been contradictory and the mechanisms of action have never been scientifically verified (NIH, n.d.).
Homeopathic remedies, however, are considered drugs, and the manufacturing and sale of products is regulated under the FDA’s Food, Drug and Cosmetic Act (FDCA) of 1983. Products are sold without a prescription, and are labeled for indication, ingredients, dilutions, and instructions for safe use. Homeopathic remedies, however, are not required by the FDA to be tested for safety and effectiveness.
DESCRIPTION OF ISSUE
The use of complementary and alternative medications, particularly for children with acute or chronic health conditions, is growing. In many cases, health care providers may be unaware of the alternative treatments used by parents, and parents may be unaware of proper dosing and side effects particular to children (Becker, 2004).
Requests that school staff administer herbs and other alternative medicines (with or without a physician’s statement) may arrive from parents in two ways: (1) in accordance with the school’s policy on over-the-counter medicines, (2) apart from the policy by suggesting that the product is a food and not subject to any restriction. Many districts are without policies to aid them in recognizing and taking appropriate action on such requests.
The school nurse must consider: (1) applicable state law and regulations including the state’s nursing practice act regulations, (2) written school policies, and (3) whether there is a significant risk to student safety by administering a product that lacks published data in standard references about its safety, efficacy, and dosages for children.
RATIONALE
School district personnel should not administer to children any substance whose safety is not established. And, although herbal products may be sold over-the-counter, unless the FDA can prove there is a danger, they are not fully regulated nor are there standardized dosing guidelines, particularly for the safe use in children. Manufacturers can make claims for the effects of these products without independent research. The bioavailability (the amount absorbed from a dose) of a specific dose of an herbal product cannot be assured across manufacturers nor from batch to batch unless the product is marked USP or NF (National Formulary) indicating voluntary compliance with standards of identity, strength, quality, and purity.
While labeling of homeopathic remedies is universally regulated, there is no requirement for safety, efficacy or pediatric dosing. Parents who use these products should not expect the medication to be administered at school unless its administration meets school policy guidelines.
School districts need to develop policies and practices for complementary and alternative medicines within the context of medication administration policy, and the school nurse must be included in the development of these policies. Local advisory councils or committees composed of school nurses, pediatric health care professionals, pharmacists, and people knowledgeable about current research on complementary and alternative medicine will assure that policies are safe and based on scientific evidence.
School nurses are in a position to educate parents about the safe use of medications and the importance of notifying the health care practitioner if complementary and alternative medications are used.
References/Resources
American Academy of Pediatrics, Committee on Children with Disabilities. (2001). Counseling families who chose complementary and alternative medicine for their child with chronic illness or disability. Pediatrics, 107(3), 598-601.
American Academy of Pediatrics, Committee on School Health Policy Statement. (2004). Guidelines for the Administration of Medication in School. Journal of School Nursing, 20 (2), 65–68.
Becker, B. & Canadian Health Network’s Complementary and Alternative Health Affiliate. (2004, October). Retrieved May 15, 2006, from www.canadianhealthnetwork.ca/servlet/contentServer?cid=.
Coerr, L. (2001). Using homeopathy for treating childhood asthma: Understanding a family’s choice. Journal of Pediatric Nursing, 16(4), 269-276.
Cohen, M.H. & Kemper, K.J. (2005). Complementary therapies in pediatrics: A legal perspective. Pediatrics, 115(3), 774-780.
Dockrell, T. R., and Leever, J. S. (2000). An overview of herbal medications with implications for the school nurse. Journal of School Nursing, 16(3), 53-58.
Hootman, J., Schwab, N., & Gelfman, M. (2001). School nursing practice: Clinical performance Issues. In N. Schwab and M. Gelfman (Eds.), Legal Issues in School Health Services, (pp. 219-222). North Branch, MN: Sunrise River Press.
Kemper, K. J., & O’Connor, K. G. (2004) Pediatricians’ recommendations for complementary and alternative medical (CAM) therapies. Ambulatory Pediatrics, 4(6), 482-487.
Lamarine R. J. (2001). Alternative medicine: More than a harmless option. Journal of School Health, 71(3), 114-116.
Levy, S. E., & Hyman, S. L. (2003). Use of complementary and alternative treatments for children with autistic spectrum disorders is increasing. Pediatric Annals, 32(10), 685-691.
National Association of School Nurses. (2001). Position statement: Research medications (Experimental and Off-label Medications in the School Setting). Scarborough, ME & Castle Rock, CO: Author.
National Association of School Nurses. (2003). Position statement: Medication administration in the school setting. Scarborough, ME & Castle Rock,CO: Author.
National Institutes of Health (NIH). National Center for Complementary and Alternative Medicine. (n.d.) Get the facts: What is complementary and alternative medicine. Retrieved May 15, 2006 from http://nccam.nih.gov/health/whatiscam/
National Institutes of Health (NIH). National Center for Complementary and Alternative Medicine. (n.d.). Research report: Questions & answers about homeopathy. Retrieved May 15, 2006 from http://nccam.nih.gov/health/homeopathy/
Patterson, S., & Graf, H. (2000). Integrating complementary and alternative medicine into the health education curriculum. Journal of Health Education, 31(6), 346-351.
Pediatric Integrative Medicine Education Project. Available at www.holistickids.org
Sinha, D., & Efron, D. (2005). Complementary and alternative medicine use in children with attention deficit hyperactivity disorder. Journal of Pediatric Child Health, 41(1-2), 23-26.
Adopted: June 2001
Revised: June 2006