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The School nurse's role in homeopathic interventions.

A school nurse posed the following question to her state's School Health Advisory Committee: "Should a school nurse be required to administer homeopathic medications to school children at the request of parents instead of implementing conventional interventions?" To respond to the dilemma this question poses, it is first necessary to understand the principles of homeopathic practice and then to discuss the possible issues involved.

As alternative approaches to health care become more popular, school nurses are being asked to participate in administering treatments and therapies not included in their nursing education. Because little is written in the medical literature about these alternatives, it is important to address the state of the science and the issues involved. This article focuses on the practices of homeopathy and how they affect the scope of practice of the school nurse. Topics addressed include a definition of homeopathy, symptomatology, administration, efficacy, and risks. Nine guidelines are offered for managing homeopathic products at school.

HOMEOPATHY DEFINED

Homeopathy is a holistic approach to treatment nearly 200 years old. The term comes from the Greek words "homo" which means similar and "pathos" which means disease or suffering.[1] This philosophy directs the practitioner to select treatments, or remedies as they are called, that actually cause the "same" symptoms from which the patient is "suffering;" the premise is that "like can cure like." This "Law of Similars" differs from conventional or allopathic medicine which usually recommends treatments that counteract the presenting symptoms.

In addition to the "Law of Similars" is the principle of potentization. This tenet promotes the use of diluted microdoses of remedies with the premise being that the more diluted the substance is, the more effective it will be. This goal is accomplished by dissolving the plant, animal, or mineral substances in a water and alcohol mixture of at least one part substance and nine parts water and alcohol mixture[1] and then vigorously shaking. The dilution process is repeated with the previous solution at least 10 times. Substances are usually diluted hundreds or thousands of times. An "x" indicates a substance has been diluted 1:10 for x times; a "c" indicates a substance has been diluted 1:100 c times; and an "m" indicates a substance has been diluted 1:1000 m times.[2]

Allopathic health care providers question whether or not dilutions greater than 12c would result in the presence of molecules of any of the original substance in the remedy. However, it is hypothesized by homeopaths that the more diluted it is, the stronger its effects will be, the longer it will last, and the fewer doses that will be needed.[2]

SYMPTOMATOLOGY

Determination of which treatment modalities should be initiated is based on the presence and pattern of symptoms rather than on specific diseases. It is believed that the body responds with varied symptomatology to adapt, to heal, and to respond to invasion or trauma. Homeopaths theorize that decreasing or suppressing signs or symptoms, as practiced in allopathy, decreases the healing potential of the body.

Each person manifests conditions differently. Just as nursing promotes individualizing patient care, so it is in deciding which homeopathic remedies to administer. Consequently, prescribing a homeopathic medication must be based on the pattern of symptoms presented by the patient and not on the condition or diagnosis. Two individuals with the same medical diagnosis or problem, such as a bee sting, may receive very different remedies based on the symptoms presented. Rarely is there a remedy that resolves all the exhibited signs and symptoms; combinations of remedies are commonly suggested.

Emphasis on symptomatology places the essential diagnostic component on the history and symptoms with which the client presents. This approach includes both subjective and objective data about the signs and symptoms; their pattern of presentation; how the symptoms are affected by environmental factors such as temperature, weather, external stimuli, food, and sleep; the patient's emotional response to the symptoms; and associated symptomatology. Once the specific individualized remedy is administered, symptoms are thought to resolve cephalocaudally, proximodistally, and in the reverse order from their appearance.[2] Some examples of common ailments of children and selected homeopathic remedies follow. Specific symptoms guide the selection of the particular remedy. Examples of remedies and the specific symptoms for which they are effective include the following:

Insect Bites and Stings

APIS -- "...for red, inflamed insect bites which cause burning or stinging pain; symptoms are worse with heat or warm applications and are relieved by cold or cool applications."[2]

LEDUM -- "the itching from the bite or sting is relieved by cold applications and is sensitive to touch."[2]

Common Cold

ACONITUM -- "...useful primarily during the first 24 hours of a cold .... wakes up with a dry, croupy cough, especially worse at night and after midnight. She has a dry mouth, shortness of breath and can't spit. The cough is worse from being cold,....lying on either side, and at night."[2]

ALLIUM CEPA -- "...profuse, watery, burning nasal discharge that is worse in a warm room and better in the open air. The nasal discharge will irritate the child's nostrils, causing pain from simply wiping his nose. He may also have profuse...non-burning tearing from the eyes. He has reddened eyes and a tendency to rub them. The child may occasionally experience a congestive headache in the front part of his head."[2]

EUPRASIA -- ...for profuse burning tears, non-burning nasal discharge, reddened sclera, reddened cheeks, and sneezing... "eye symptoms are worse in the open air" ...nasal discharge "is worse at night, while lying down, and in windy weather...the cold moves to the larynx, creating a hard cough and a hoarse voice."[2]

PULSATILLA -- for thick yellow or greenish mucus and a [non-irritating] discharge... "nasal congestion is worse at night, especially upon lying down, which leads to mouth-breathing during sleep. The nasal congestion...is worse in a warm room."[2]

Fever

ACONITE -- for fever of sudden onset with associated fear, pale face, restless, and thirsty; child feels better in fresh air and worse in warm rooms and at midnight.

BELLADONNA -- for fever of sudden onset with flushed face, dry hot skin, and stating eyes. Child feels better standing or sitting uptight and feels worse lying on the right side and at night.

FERRUM PHOS. -- for fever of gradual onset in the early stages of infection; manifested by red cheeks, profuse sweating and shivering, throbbing headache, and a weak, rapid pulse. Feels better with application of cold compresses and gentle exercise and worse by lying on the tight side and between 4 and 6 am.[1]

CONDITIONS TREATABLE BY HOMEOPATHIC PHYSICIANS

Some of the more common childhood ailments considered treatable by homeopathic methods include allergies, anxiety, bed wetting, behavioral problems, cough, earache, fever, growing pains, headaches, hives, motion sickness, and ringworm. While most of these conditions can be diagnosed and treatment remedies identified by anyone using one of the available homeopathic manuals, homeopathic physicians recommend that symptoms considered part of a more complex picture or those that do not respond to treatment require their attention. Most homeopathic physicians recognize the value of conventional medical treatment and surgery for urgent and potentially dangerous conditions.[2]

Risks of Homeopathic Remedies

Supporters have touted homeopathy as nontoxic and "exceptionally safe."[3] Because of the use of very dilute products and because the doses are so small, the potential for side effects is considered minimal. Readers of homeopathic manuals are told not to worry if they choose the wrong medicine or remedy for their children because most often "nothing happens."[2] Ullman admits that a small risk can arise "when parents continue to give a homeopathic remedy to their child after it has proven helpful and the symptoms have disappeared."[2] It is also acknowledged that delaying access to professional medical help when it is warranted may be the greatest risk of all.[2]

Homeopathic remedies were identified by administering products to individuals without symptoms and noting their reactions. Symptoms that develop in normal individuals are called "provings." While these products produce symptoms, homeopaths still purport there is no danger in a child taking the entire bottle.[2] However, one report[4] describes a child developing hyponatremia and edema while being treated for eczema, and assorted reports in journals originating outside of the United States detail side effects from homeopathic treatments, such as pruritis and poisoning with potentially toxic substances.

Dosages of homeopathic remedies vary with the degree of potentization (dilution and shaking). Standardization of these products has only occurred within the past decade.[3] Homeopathic products are not FDA regulated and are sold over the counter in drug store and health food stores. Proponents insist that most are actually food products rather than medications, yet some remedies are made from arsenic, bella donna, ipecac, and iron phosphate.

Efficacy of Homeopathic Treatment

Much debate continues over the efficacy of homeopathic remedies. Most published studies promoting the effectiveness of these therapies are case studies or experimental studies with small sample sizes. One placebo-controlled, double-blind study conducted in Nicaragua demonstrated a significant decrease in the duration of diarrhea in children under age five treated with homeopathic preparations compared to those not treated. However, it was difficult to compare the outcomes by specific pathogens. Because each of the 81 children's homeopathic remedies was specific to their symptoms, 1.8 different medicines were prescribed. This practice of individualized treatments, which is inherent to the philosophy of homeopathy, makes it difficult to replicate the study.

Another randomized, double-blind, placebo-controlled study with a sample of 175 attempted to identify whether or not homeopathic treatments decreased the symptomatology in children with recurrent upper respiratory track infections. The findings demonstrated a small difference in favor of homeopathic remedies, but the findings were not statistically significant.[6] An urgent need remains to develop an empirical base for the practice of homeopathy.

Administration of Homeopathic Remedies

Homeopathic remedies are usually in the form of a very small tablet with a lactose or sucrose base or as a liquid. It is recommended, that tablets be placed under the tongue so they dissolve slowly; they should not be washed down.[2] For maximum efficacy, practitioners recommend they be taken on an empty stomach. Handling the medications should be avoided.

Homeopaths suggest that as few doses as possible be given, yet patients should have as much as they need. Those new to administering homeopathic preparations are urged to use the 6, 12, 30 potency rule of x or c. Doses should be repeated if an increase in severe symptoms exists, and potency should be increased with intense symptoms.[2] However, if "intense" symptoms are present after 24 hours and if "mild" symptoms are present after 36-48 hours, a change in the remedy is warranted. Giving more than two remedies for any one illness is not recommended for the novice provider.

Certain items are thought to counter the effectiveness of homeopathic remedies. Items include camphorated products, mint or mentholated products (including toothpaste and cough drops), electric blankets, dental work, and steroids.[2] Remedies should be kept separate from these pungent odors and the bottle cap should be replaced promptly. Ullman recommends "to not place them in medicine cabinets due to the presence of past or present odors."[2] The products are thought to be sensitive to direct sunlight. Therefore, long-term exposure to direct sunlight or other intense light should be avoided. Temperatures higher than 100 [degrees] F may also negatively alter the remedies.

HOMEOPATHIC REMEDIES IN THE SCHOOL SETTING

Nurses can educate parents and children about the variety of treatments, their alternatives, and their possible sequelae so they can make informed choices. This teaching and the parent's response to it should be included in the child's health record. Parents should be encouraged to share information with the school nurse about both the allopathic and homeopathic remedies administered to their child. This information, plus the allopathic medications and/or homeopathic remedies they are requesting and the symptoms for which they are to be given, also should be recorded.

The National Association of School Nurses approved a position statement that addresses the issue of natural and homeopathic remedies for self-limiting conditions.[7] This policy for medication administration in the school setting recommends that school nurses follow local regulations, school nurse standards of practice, state nurse practice acts, and state laws.

School nurses should remember that since the specific symptoms and patterns of symptoms guide the determination of the particular therapy, no one therapy is appropriate for any one symptom. Treatment of pain or bee sting is not the same from one situation to another. The situation must be reviewed and a determination made as to which remedy would be most appropriate. It may also be that the dosage/dilution needed for one set of symptoms is not the same as for another. Therefore, to keep a stock remedy in the school health office may not be the best practice.

Because it is always recommended that the fewest number of doses possible be administered, it could be recommended to parents that they administer the therapy to the child prior to going to school. This practice should decrease or eliminate the doses needed during the school day. It can also be recommended that the parent come to school to administer the remedy.

It would be helpful to have a clear, written plan of action that requires a parent's signature for emergency intervention with conventional medications if the homeopathic treatment is not effective and the nurse determines that conventional medications, such as Benadryl or epinephrine, must be given for quickly progressing hives or an allergic reaction to bee stings.

School nurses should only administer remedies for which they have parent/guardian authorization and information regarding the chemical composition, uses, and possible interactions. If school nurses are allowed to give nonprescription medications, it is important to check with the state board of pharmacy to ensure the homeopathic preparations requested for the child are considered in that category. If a homeopath has ordered the remedies, the board of pharmacy can also inform you as to whether or not homeopaths in that state have prescriptive authority.

The following guidelines for the provision of nontraditional remedies to students in the school setting are offered for school nurses as a prototype:

1) The remedy is prescribed by a licensed health care provider with prescriptive privileges or the remedy is a nonprescription, commercially prepared preparation age-appropriate for the student.

2) Provision of the remedy must be requested in writing by the parent/guardian.

3) A record that includes the date of the request and the purpose of the remedy as well as the record of the time and dosage administered is kept.

4) A careful history of allergies is maintained.

5) Use of the remedy does not contradict the state's nurse practice act or any standing orders or protocols for school nurses in that school district.

6) Parents are made aware of treatments currently accepted as the standard of practice. Parents also should be informed that the standard of practice will be invoked in an emergency situation. Document that this notification was provided and the parents' response.

7) Parent or health care provider must provide information regarding the remedy, its purpose, degree of dilution, any toxicity or interactions, proper dosage and storage, the symptoms which the provings produce, the specific symptoms for which the remedy is to be given, and any other instructions necessary for the safe provision of the remedy.

8) The remedy is properly labeled with content, dosage, time and route of administration, student's name, date, and name of prescribing practitioner (if prescribed). 9) Long-term provision of remedies must be re-authored each academic year by the parent and practitioner (if prescribed).

CONCLUSION

It is important to respect the needs of the child and the wishes of the families. It is also important to provide safe and competent care. While science has not provided sufficient documentation that homeopathic treatments provide a significant improvement in symptoms, it is an "accepted" alternative therapy. School nurses must continue to provide culturally competent care that ensures child safety. Above all, however, is the fact that continuing communication with parents is essential. 1

References

[1.] Lockie A, Geddes N. The Complete Guide to Homeopathy: The Principles and Practice of Treatment. London: Dorling Kindersley; 1995.

[2.] Ullman D. Homeopathic Medicine for Children and Infants. New York, NY: Putnam Publishing Group; 1992.

[3.] Lockie A. The Family Guide to Homeopathy: Symptoms and Natural Solutions. New York, NY: Simon & Schuster, Inc; 1989.

[4.] Spigelblatt LS. Alternative medicine: should it be used by children? Curr Problems in Pediatrics. 1995;25:180-188

[5.] Jacobs J, Jimenez LM, Gloyd SS, Gale JL, Crothers D. Treatment of acute childhood diarrhea with homeopathic medicine: a randomized clinical trial in Nicaragua. Pediatrics. 1994;93(5): 719-725.

[6.] deLange de Klerk ESM, Blommers J, Kuik DJ, Bezemer PD, Feenstra L. Effect of homeopathic medicines on daily burden of symptoms in children with recurrent upper respiratory track infections. Br Med J. 1994;309:1329-1332.

[7.] Medication Administration in the School Setting: Position Statement. Scarborough, Maine: National Association of School Nurses; 1997.

Janice Selekman, DNSc, RN, Professor and Chair, Dept. of Nursing, University of Delaware, Newark, DE 19716; Elizabeth Thomas, MEd, RN, CSN, School Nurse and School Nurse Coordinator, Christina School District, Newark, DE 19711: and Kay McLean, BSN, RN, Staff Nurse, Center for Pain Management, Christiana Care Health System, Wilmington, DE 19718. This article was submitted January 26, 1998, and revised and accepted for publication July 20, 1998.
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Author:Selekman, Janice; Thomas, Elizabeth; McLean, Kay
Publication:Journal of School Health
Date:Oct 1, 1998
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