READERS' FORUM Homeopathy: Good or bad science? I am baffled by "Homeopathy in pediatricsno harm likely, but how much good?" (May 2003). Some of the recommendations in the article are laughable. Table 2, with its recommendation of remedies based on "mind," "general," and "stools," is reminiscent more of a horoscope than of scientific material. Can the authors provide any reasonable documentation as to what such advice is based on, other than New Age mumbo-jumbo or centuries' old superstition? Co-author Dr. Jennifer Jacob's vignette on acute otitis media has all the flavor of a testimonial rather than a true case history. In this case, she prescribed a potion with a 200C potency. A potency of 1C corresponds to a dilution of 1 to 100, 2C is 1 to 10,000, and so on. A potency of 200C (1 to 100200 or 1 followed by 400 zeroes) is a mathematical impossibility, as estimates put the total number of molecules in the universe at about 1 googol (1 followed by 100 zeroes). In fact, laws of chemistry stipulate how dilute a solution can be before losing all of the original substance. That number is 6.022 x 1023, or Avogadro's number. It is clear that the authors are biased in favor of homeopathic treatment and have not analyzed scientific studies on homeopathy in an objective fashion. Otherwise, they would have arrived at the same conclusion that many legitimate scientific publications, such as the Review of Epidemiology (1990), the French journal Prescrire International (1995), Lancet (1997), Homeopathic Medicine Research Group (1996), and Medical Letter on Drugs and Therapeutics (1999), have reached: The vast majority of scientific studies on homeopathic remedies are flawed, and there is no scientific proof that homeopathic remedies are effective. The skeptic professes: "Extraordinary claims require extraordinary proof." Homeopathy does make extraordinary claims that counter many laws of physics, yet it fails to provide substantial, let alone dramatic, proof. Homeopathy will never cure neuroblastoma. It will never be an alternative for the treatment of meningococcemia or appendicitis. The only instances where "success" can be even remotely attributed by its most fervent disciples is as an adjunct in the "treatment" of mild, self-resolving illnesses as a placebo effect. In the last 50 years, modern medicine has achieved objectives that were unthinkable just decades before. It has done so by utilizing the scientific method with rigor. There is no reason to abandon this method of study and investigation. Pierpaolo Palmieri, MD Mission, Texas The authors of "Homeopathy in pediatricsno harm likely, but how much good?" conclude their article by saying that "we are optimistic about the value of the individualized approach to treatment and the promising results of the randomized, controlled trials conducted so far." Although the article addresses interesting data regarding homeopathy for acute otitis media and acute diarrhea, it doesn't mention the known limitations of homeopathy. Two randomized, double-blinded, placebo-controlled trials of homeopathy for asthma revealed no difference between homeopathy and placebo.1,2 Given this strong evidence, I advise patients with asthma that homeopathic providers have not proved that their therapies are more effective than a sugar pill when studied by rigorous scientific methods. Despite this evidence, asthma is the most common reason patients see homeopathic physicians.3 I am very interested in incorporating complementary and alternative medicine into my practice. I also believe, however, that we, as physicians, must hold these therapies up to the same scrutiny that we hold traditional (allopathic) medications to. Through critical study, we can learn which alternative medicines are safe and effective for our patients. Matthew I. Fogg, MD Philadelphia, Pa. REFERENCES 1. White A, Slade P, Hunt C, et al: Individualised homeopathy as an adjunct in the treatment of childhood asthma: A randomised placebo controlled trial. Thorax 2003; 58:317 2. Lewith GT, Watkins AD, Hyland ME, et al: Use of ultramolecular potencies of allergen to treat asthmatic people allergic to house dust mite: Double blind randomised controlled clinical trial. BMJ 2002;324:520 3. Jacobs J, Chapman EH, Crothers D: Patient characteristics and practice patterns of physicians using homeopathy. Arch Fam Med 1998;7:537 Author reply: Homeopathy is a controversial therapy, mainly because of the highly diluted nature of the medicines used. Rejecting a therapy because of lack of understanding of its mechanism, however, would have kept aspirin (and many other common drugs) out of clinical use until the 1960s. Nevertheless, recent meta-analyses and rigorous reviews have concluded that homeopathic remedies are significantly more effective than placebo for treating certain conditions, such as influenza, allergic rhinitis, and childhood diarrhea.14 For example, the Lancet article cited by Dr. Palmieri found an odds ratio of 2.45 in favor of homeopathy, but also concluded that, because of a lack of replication, there was no single clinical condition for which homeopathy could be considered efficacious. The evidence for homeopathic treatment of asthma remains inconclusive, as the three studies conducted have had differing results (two of those studies used homeopathic immunotherapy, which is not generally used in homeopathic practice).57 Although homeopathy is certainly a safe treatment for many common pediatric illnesses, it would be unwise for patients who require medical therapy for a serious condition (such as insulin for type 1 diabetes) to abandon lifesaving therapies and rely solely on homeopathic remedies. Further research will help elucidate the optimal role of homeopathic remedies in the comprehensive treatment of pediatric patients. We encourage readers who are interested in this subject to review the evidence themselves. Kathi J. Kemper, MD, MPH Jennifer Jacobs, MD, MPH REFERENCES 1. Kleijnen J, Knipschild P, ter Riet G: Clinical trials of homeopathy. BMJ 1991;302:316 2. Linde K, Clausius N, Ramirez G, et al: Are the clinical effects of homeopathy placebo effects? A meta-analysis of placebo-controlled trials. Lancet 1997;350:834 3. Jonas WB, Kaptchuk TJ, Linde K: A critical overview of homeopathy. Ann Intern Med 2003;138:393 4. Jacobs J, Jonas WB, Jimenez-Perez M, et al: Homeopathy for childhood diarrhea: Combined results and meta-analysis from three randomized, controlled clinical trials. Pediatr Infect Dis J 2003;22:229 5. Reilly D, Taylor MA, Beattie NG, et al: Is evidence for homeopathy reproducible? Lancet 1994;344:1601 6. Lewith GT, Watkins AD, Hyland ME, et al: Use of ultramolecular potencies of allergen to treat asthmatic people allergic to house dust mite: Double blind randomised controlled clinical trial BMJ 2002;324:520 7. White A, Slade P, Hunt C, et al: Individualised homeopathy as an adjunct in the treatment of childhood asthma: A randomised placebo controlled trial. Thorax 2003;58:317 Screening for autism Neither "How you can implement the AAP's new policy on developmental and behavioral screening" nor "Is it autism?" (April 2003) mentioned the Modified Checklist for Autism in Toddlers (M-CHAT) parent screening questionnaire as an aid in screening young children for autism. It is designed to be completed by parents and scored by the clinician, has only 23 questions, and does not require the cooperation of the child in your office. A copy of the M-CHAT and scoring guidelines is available on the Web site www.firstsigns.org . It can be applied to children of concern as early as 18 months of age. Yvonne Sudarshan, MD (mother of an autistic son) Brownsville, Texas Author reply: The measures we listed in "How you can implement the AAP's new policy on developmental and behavioral screening" are designed to be used with every child, no matter what, at every well visit. They detect a broad range of possible problems including speech-language impairment, mental retardation, learning disabilities, and autism spectrum disorders. Once a broad-band tool detects a possible difficulty, the M-CHAT (or similar measure) can then be used to look specifically for the possibility of a spectrum disorder. But the M-CHAT is not designed to be used in the very first stage of screening. Thanks to Dr. Sudarshan for mentioning First Signs, which is an excellent resource for parents and professionals. The organization's Web site, www.firstsigns.org , has information on the American Academy of Neurology policy on autism screening, which includes steps to be taken when children show difficulties on front-line tools such as PEDS (Parents' Evaluations of Developmental Status) or ASQ (Ages and Stages Questionnaire). The next steps include screening specifically for autism, checking lead levels and hearing, and so on. Frances Page Glascoe, PhD Michelle Macias, MD Readers' Forum. Contemporary Pediatrics July 2003;20:103.
