Blue Poppy: Pediatric Asthma

Asthma is a serious chronic lung disease affecting over two million Canadians. Asthma is a disease that is more prevalent in children, affecting 10-15% of children in Canada and making it the most common chronic disease of childhood in Canada and many other countries in the West. This disorder is typically episodic and remittent in nature and is characterized by the narrowing of the large and small airways due to spasm of the smooth muscles of the bronchi, edema, inflammation of the bronchial mucosa and production of tenacious mucus. Asthma can begin at any age, but most people with this condition first develop it before the age of five years old. The main symptoms of asthma are shortness of breath, tightness in the chest, and coughing and wheezing. The frequency and severity of symptoms differ from person to person. There are four types of asthma: 1) allergic, 2) exercise-induced bronchospasm (EIB), 3) reactive airway disease (i.e., asthma that only occurs during colds) and 4) miscellaneous types. Included in the miscellaneous group is heartburn or reflux asthma and stress-induced asthma. Improperly treated asthma may lead to a life-time of asthma. Children can sometimes out-grow their asthma, and half of these children will see a lessening of their symptoms as they move into adolescence. However, approximately 50% of this group will see their asthma return, often when they are in their 30s and 40's. Asthma can cause death, and approximately 10 children and 450 adults die from asthma each year in Canada.

Fifty-two percent of children currently receiving treatment from a modern medical doctor have poorly controlled asthma (according to the "Asthma in Canada" survey - the largest and most comprehensive survey to be done on the status or state of asthma in Canada). Poorly controlled asthma leads to an increase in symptoms of asthma during the day and night, absenteeism (i.e., school or social engagements), exacerbations (i.e., more frequent acute attacks), and increased need for "rescue" medication and a lower tolerance for physical activity. Poorly controlled asthma is a burden to the child and their family as well as health care systems as these patients are more likely to require urgent care and hospitalization. Although statistics show that more than 50% of these children are suffering with poorly controlled asthma, 88% of parents continue to believe their child's asthma is controlled. For instance, 47% believe their child's asthma is very well controlled and 41% believe it is adequately controlled. Moreover, 77% of general physicians and 90% of specialists surveyed also believe their asthma patients are optimally controlled even though statistics demonstrate otherwise. The Western medical treatment of asthma focuses on using a variety of medications depending on the severity and staging of the disease. For a more detailed discussion of what forms of Western medicine are used to treat bronchial asthma, please see the chapter on this subject in The Treatment of Modern Western Medical Diseases with Chinese Medicine by Flaws and Sionneau, Blue Poppy Press, Boulder, CO, 2001.

Bronchial asthma is discussed under the traditional Chinese medical disease categories of chuan zheng, panting condition, chuan ke, coughing and panting, chuan cu, hasty breathing, xiao zheng, wheezing, condition, and xiao chuan, wheezing and panting. The modern approach to the treatment of asthma was first discussed in detail by the famous Chinese doctor, Zhu Dan-xi, approximately 600 years ago. Since then, the treatment of this disease has been refined and improved upon by many generations of Chinese doctors. Pediatrics is a distinct specialty in traditional Chinese medicine. The majority of children seeking treatment for their asthma would see a traditional Chinese medical (TCM) pediatrician. In TCM, the treatment of children is often different from adults, and, therefore, most practitioners of Chinese medicine do not treat children (especially practitioners in the West). I have been fortunate to complete my post-graduate studies in the specialized area of TCM pediatrics. In addition to finishing these studies, I have had the unique opportunity to work with pediatricians in China who specialized in the treatment of pediatric asthma. I have discovered during this time that it is unfortunate that most TCM practitioners do not treat children because most pediatric health problems, including asthma, can be resolved quite effectively with the use of Chinese medicine.

The causes of pediatric asthma can be rather complex due to the multitude of factors that can aggravate or predispose an individual to this disease. In TCM, the five causes of all illnesses (including asthma) are improper diet, emotions, lifestyle, external environment, and constitution (i.e., genetics). Any or all of these factors may cause or aggravate asthma. Similar to adult asthma, pediatric asthma is characterized by two stages: acute and remission. Triggers for acute attacks in children include allergens (i.e., external environment), environmental exposures to exercise (i.e., lifestyle) and infections, and strong emotions (not as common a factor in children). Studies have shown children with a family history of asthma are more likely to develop asthma. In addition, most children with asthma (up to 80%) also suffer from significant allergies, including having much higher incidences of other atopic diseases, such as allergic rhinitis, urticaria, and eczema. A child with a weaker constitution, such as a child whose mother smoked while they were pregnant or a child who was born with a lower birth weight, are also more likely to suffer from asthma.

Traditional Chinese medicine recognizes that children have unique physiological characteristics and cannot be considered as just miniature adults. When treating asthma, one of the main differences of pediatric physiology to be considered is that a child's digestion (i.e., spleen and stomach) is immature, especially before the age of six years old when most asthma begins. This immaturity and weakness of the digestion predisposes a child to experience an incomplete breakdown of food and the accumulation of phlegm. It is said in Chinese medicine that, 'The spleen is the source of phlegm production," and, "The lungs are the place where phlegm is stored." Asthma is a good example of what happens when phlegm is produced by a weak digestion, and this pathological matter accumulates in the lungs. Clinically, "phlegm in the lungs" obstructs the circulation of qi in the lungs and can manifest as a stuffy and/or runny nose, sneezing, coughing, and/or asthmatic wheezing. Phlegm is clearly a key component in all types and stages of pediatric asthma. Therefore, when older Chinese doctors teach younger doctors will often repeat the statement that, "There is no asthma without phlegm."

Unfortunately, in society today, children often consume a diet that has a large amount of fatty and chilled foods which can cause phlegm. Moreover, foods such as dairy products and peanuts also increase phlegm and should be restricted. It is important to avoid any known food allergies the child may have as well as foods and medications that may damage the spleen and stomach, such as excessive chilled, raw foods, sugar and sweets, and antibiotics.

Spleen qi vacuity also can result in defensive qi not securing, thus allowing easy entry of external evils which hinder and obstruct the lungs functions of diffusing and downbearing. When these evils combine with the phlegm in the lungs discussed above, the lung qi's diffusing and downbearing is more severely affected. If phlegm or dampness endures over a period of time, this may lead to transformation of heat, and, when these two combine, they result in phlegm heat. Blood stasis may also be a factor and is often the result enduring stagnation of qi and obstruction of phlegm dampness. Kidney vacuity due to former heaven natural endowment insufficiency or enduring disease (according to some doctors) is also a factor to consider while treating pediatric asthma. However, kidney vacuity of children is usually only addressed in the remission stage.

As mentioned above, Chinese medicine divides asthma into two stages - acute and chronic or remission. The discussion and translations in this article focus on the acute phase. In an up-coming issue of the Blue Poppy Chinese Medical Journal, I will discuss various treatments used in the remission stage. In TCM, acute asthma is divided into two patterns: hot and cold. Both types share the main symptoms of asthma which include shortness of breath, tightness in the chest, coughing, and wheezing. Due to a child's pure yang constitution, the hot pattern of asthma is much more commonly seen in clinical practice. Of course, it is possible to have heat and cold occurring simultaneously, for example in cases of external cold and internal heat. The hot pattern presents with some or all of the following symptoms: cough with yellow phlegm, fever, red face, yellowish urine, dry stools or constipation, thirst with a desire to drink, red tongue with yellow fur, and a slippery, rapid pulse. In my opinion, the cold pattern is really a pattern of acute asthma without heat and may include the following symptoms: cough with clear, watery, white-colored phlegm, a cold body with no perspiration, a dull, lusterless facial complexion, chilled limbs, no thirst or only thirst for hot drinks only, thin, white, or slimy, white tongue fur, and superficial, slippery pulse.

In general within Western medicine, the acute stage (a so-called asthma attack) is most often treated with an inhaled bronchodilating medicine for 1-2 days. Therefore, most children visiting a TCM practitioner in the West will already be taking some type of "puffer" (i.e., inhaled bronchodilator). This is a very practical and convenient medicine because asthma attacks frequently occur in the middle of the night. However, it is important to remember that TCM is also effective during these acute episodes even without the use of such a puffer, and the main modality used in the treatment of pediatric asthma in Chinese medicine is internally administered "herbal" medicine. In such cases, the herbal formulas used are customized according to the child's TCM pattern, presenting symptoms, and the stage of the patient's asthma. Acupuncture can also be helpful in the acute stage, but, if it is used, it is typically only an adjunctive modality to an internally administered formula. Such a formula usually consists of 10-15 ingredients which are chosen based on the individual's clinical presentation. At this stage, the child is closely monitored, with clinical visits occurring every 4-7 days. Upon return visits, the herbal formula is adjusted or modified as the patient's condition improves.

The summaries of the following four recently published Chinese clinical trials exemplify how Chinese medicine can be used to effectively treat the acute stage of pediatric asthma.

Study 1: "Ping Chuan Tang Jiang (Calm Panting Sugar Syrup) for the Treatment of 79 Cases of Asthma (i.e., Pediatric Panting and Wheezing)" by Xu Hui-fu et al., He Bei Zhong Yi Za Zhi (Hebei Journal of Chinese Medicine), # 1, 1997, p. 18

All 79 patients involved in this study were seen as out-patients from September 1995 to April 1996. All patients in the study had acute asthma for 1-2 days. See Table 1 below for all other relevant clinical data.

Table 1. The Clinical Data of 79 Cases of Pediatric Asthma Including Age, Sex and Severity.

Formula: Su Zi (Perillae, Frutus), Bai Jie Zi (Sinapsis, Semen), Lai Fu Zi (Raphani, Semen), Wu Wei Zi (Schisandrae, Fructus), Zhi Ban Xia (Pinelliae, Rhizoma Preparata), Gui Zhi (Cinnamomi, Ramulus), Di Long (Pheretima), Qin Pi (Fraxini, Cortex), and Jie Geng (Platycodi, Radix), each 10 grams, and Da Qing Ye (Isatidis, Folium ), 30 grams

The medicine was decocted in the standard way until the amount of the resulting decoction was equal to one milliliter per one gram of uncooked herb. [Note: The formula above contains 130 grams of uncooked herbs].

Dosage: <1 year old 10ml/3 times per day, 1-3 years old 15 ml/ 3 times per day, 3-5 year old, 20 ml/ 3 times per day and > 5 years old 20ml/4 times per day. One week equaled one course of treatment. During the treatment phase, all other medication including asthma medication and antibiotics were stopped.

Clinical cure: After one week of treatment, the internal symptoms and bodily signs were resolved and the child was able to stop taking medicine.

Improvement: After one week of treatment, the internal symptoms and bodily signs were obviously reduced but the patient continued to take the medicinal syrup.

Table 2. The Comparison of the Treatment Results of the Three Patterns of Pediatric Asthma

Pattern	Number of Cases	Clinical Cure	Improvement	No Results	Total Amelioration Rate
Wind-cold	28	8	13	7	75%
Phlegm-heat	11	1	7	4	72.7%
Phlegm-damp	40	17	20	3	92.5%
Total	79	28	40	11	86%

There was a statistical difference between the amelioration rate of the phlegm-damp pattern group and the wind-cold pattern group, X2 = 4.03, P < 0.05. By observing the amelioration rate using the above chart it is obvious the phlegm-damp group achieved better results than the other two groups (wind-cold and phlegm-heat groups).

Study 2: "Transform Phlegm and Dispel Stasis Method in the Treatment of 120 Cases of Pediatric Asthma (Panting and Wheezing)" by He Xian-ting, Hu Nan Zhong Yi Za Zhi (Hunan Journal of Chinese Medicine), # 4, 1997, p. 41

Among the 120 patients included in this study, 68 cases were male and 52 were female. The patients were less than one year old in 21 cases, 86 cases were 2-6 years old, and 13 cases were more than seven years old. The course of disease was less than 10 days in 25 cases, 11-30 days in 42 cases, 2-6 months in 19 cases, 7-12 months in 16 cases, and more than one year in 18 cases.

Formula: Hu Zhang (Polygoni Cuspidati, Rhizoma), Dan Shen (Salviae Miltiorrhizae, Radix) each 10-15 grams, Ban Xia (Pinellia, Ternatae), Chuan Bei (Fritillariae Cirrhosae, Bulbus), Chuan Xiong (Chuanxiong, Rhizoma), Xing Ren (Armeniacae, Semen), Niu Xi (Achyranthis Bidentatae, Radix), Gua Lou Ke (Trichonsanthis, Pericarpium), Bai Jie Zi (Sinapis, Semen), and Tao Ren (Persicae, Semen), each 4-7 grams

For aversion to cold with no sweating, mix-fried Ma Huang (Ephedrae, Herba) was added.

For fever and vexation and agitation, Zhu Ru (Bambusae, Caulis in Taeniam) and Yu Xing Cao (Hedyotis Diffusae, Herba) were added and Zhe Bei Mu (Fritillariae Thunbergii, Bulbus) was used instead of Chuan Bei Mu.

For torpid intake with a thick, slimy tongue fur, Lai Fu Zi (Raphani, Semen) was added.

For a vacuous body and spontaneous sweating, Huang Qi (Astragali, Radix) was added.

Clinical Cure: Asthma disappeared and there was no wheezing on auscultation - 68 cases (56.7%).

Marked improvement: The asthma had basically disappeared and there was only slight wheezing on auscultation - 27 cases (22.5%).

Improvement: The symptoms of asthma had decreased and there was decreased wheezing on auscultation - 11 cases (12.5%).

No improvement: There was no change in the patient's condition - 10 cases (8.3%).

If an individual has repeated acute episodes of asthma that are not cured right away, this can cause the lung qi to become stagnant and obstructed. If the qi is stagnant, [this can lead to] blood stasis and the lung's network vessels [becoming] static and obstructed [because] the movement of blood is inhibited. In clinical practice, the symptoms of stasis and stagnation that children manifest include blue (gan) lips, a reddish-purple tongue, and a cyanotic finger vein. Therefore, phlegm and stasis are the key [factors to address when] treating acute asthma. To treat asthma in the past, the author often used Ma Huang and Su Zi to downbear qi and calm panting, but the results were not very good, and, in the course of time through clinical practice, [the author] recognized that the key disease mechanism of asthma is phlegm and blood stasis. Since adopting the method of transforming phlegm and dispelling stasis, the author's results in treating asthma have improved. However, children's viscera and bowels are delicate and their form qi is not full. Therefore, this method must not be used excessively in order to prevent this treatment from damaging the righteous.

Study 3: "The Treatment of 102 Cases of Pediatric Asthma with Ding Chuan Tang Jia Jian (Settle Wheezing Decoction with Additions & Subtractions)" by Yang Li-jun, Zhe Jiang Zhong Xi Yi Jie He Za Zhi (Zhejiang Journal of Integrated Chinese-Western Medicine), #5, 1997, p. 287

Treatment group (102 cases): 54 males and 48 females. All were between 3-12 years old.

Comparison group (50 cases): 26 males and 24 females. All patients were between the ages of 2-12 years old.

Ding Chuan Tang Jia Jian (Settle Wheezing Decoction with Additions & Subtractions): Bai Guo (Gingko, Semen), Xing Ren (Armeniacae, Semen), Huang Qin (Scutellariae, Radix), Zhi Ban Xia (Pinelliae, Rhizoma Praeparatum), Sang Bai Pi (Mori, Cortex), Zi Su Zi (Perillae, Frutus), and Kuan Dong Hua (Farfarae, Flos), each 10 grams, and Gan Cao (Glycyrrhizae, Radix), 5 grams

For red tongue with yin vacuity, 15 grams of Sheng Di (Rehmanniae, uncooked Radix) were added.

For chronic (enduring) panting, 10 grams of Wu Wei Zi (Schisandrae, Fructus) were added.

An appropriate amount of water was added to the above medicinals and then decocted until 100 milliliters remained. One packet was taken each day after being divided into 3-4 doses per day. Seven days equaled one course of treatment.

Comparison group: 2.5 mg/kg of the unidentified Western medicine Luo Li De Pian was taken orally every 12 hours as well as Fei Nai Geng Stop Coughing Syrup 1 ml/ year of age taken three times per day. Seven days equaled one course of treatment.

Marked improvement: The asthma went into remission and the wheezing on auscultation disappeared.

Improvement: Clinical symptoms were reduced and there was only slight wheezing on auscultation.

Treatment group: Seventy-two cases had marked improvement, 26 cases improved, and four cases had no improvement. On average, the rapid breathing was resolved in 1.2 days and the cough disappeared in 4.1 days. [In addition,] the wheezing on auscultation disappeared in 4.8 days on average. In this group, 56 cases also had a fever that was reduced in 1.8 days on average. According to these statistics, 71% of patients had marked improvement and 25% of cases improved, for a total amelioration rate of 96%.

Comparison group: Twenty-five cases had marked improvement, 14 cases improved, and 11 cases had no improvement. On average, the rapid breathing was resolved in 1.3 days and the cough disappeared in 4.5 days. [In addition,] the wheezing on auscultation disappeared in 5 days on average. In this group, 26 cases also had a fever that was reduced in 1.9 days on average. According to these statistics, 50% of patients had marked improvement and 28% of cases improved, for a total amelioration rate of 78%.

In clinical practice, pediatric eczema often belongs to the TCM pattern of cold evils externally fettering and phlegm heat brewing internally. Therefore, the main treatment principles used are to diffuse the lungs, settle wheezing, clear heat, and transform phlegm. In the formula Ding Chuan Tang Jia Jian, Ma Huang diffuses the lungs and levels panting, and Bai Guo constrain the lungs and settle panting. One medicinal opens and the other contracts, making these ingredients the two most important medicinals in this formula. Xing Ren, Zi Su Zi, and Ban Xia transform phlegm and descend the qi. Sang Bai Pi, Kuan Dong Hua, and Huang Qin clear heat and depurate the lungs. Gan Cao regulates and harmonizes all other medicinals. Therefore, this formula addresses the main d