Pediatric Earaches & Food Stagnation

Earaches are one of the most common and distressing complaints in infants and toddlers. Not only are earaches painful in and of themselves, their routine treatment in Western medicine by antibiotics often leads to post-antibiotic spleen vacuity syndrome, especially when antibiotics are used again and again for recurrent earaches. Although Chinese medicine treats pediatric earaches very well, the majority of the Chinese medical literature on this disease is misleading in terms of pediatric pattern discrimination and treatment. Most Chinese pediatric texts do not list earache as a specifically pediatric disease. Therefore, earache or otitis media mainly shows up in general internal treatment manuals which are primarily oriented towards adults and do not commonly take into account the unique disease mechanisms at work in infants and young children.

Wu & Fischer’s Practical Therapeutics of Traditional Chinese Medicine published by Paradigm Publications is one of the best English language Chinese medical treatment manuals available. However, its discussion of earache, under the heading "Purulent Ear (Ting Er)," is similarly misleading when it comes to the pattern discrimination and treatment of pediatric otitis media. In that book, Wu and Fischer identify the patterns corresponding to purulent ear as: 1) external wind heat, 2) exuberant liver-gallbladder fire, 3) a damp-encumbered vacuous spleen, and 4) kidney yin vacuity with toxin accumulation.^[1]

While some practitioners, based on Western medical ideas about otitis media, assume that all acute otitis media is due to external invasion of wind heat evils, it is actually difficult to substantiate this in real-life clinical practice. The standard signs and symptoms of a wind heat exterior pattern are: emission of heat (or fever), slight or no aversion to chills, no or impeded sweating, sore throat, headache, possible nasal congestion and/or sneezing, possible cough with sticky, yellow phlegm, a red tongue, and a floating, rapid pulse. Although one can identify emission of heat, nasal congestion, thick, yellow mucus, and cough in infants, it is difficult or impossible to identify aversion to chill, sore throat, and headache in infants. A red tongue is not a definitive sign of wind heat exterior pattern although it is a definitive sign of heat, and it is difficult to do accurate pulse diagnosis in babies, whether that is actual pulse diagnosis at the wrist or visual inspection of the vein on the index finger. Therefore, it is difficult to definitively substantiate the presence of a wind heat external pattern in infants and really little children.^[2]

As Julian Scott says in Acupuncture in the Treatment of Children, liver depression-depressive heat resulting in earache does not clinically manifest until after seven years of age.^[3] Hence, the pattern of liver-gallbladder exuberant fire does not play a part, at least as a simple, discreet pattern in infants and toddlers. Spleen vacuity with damp encumbrance mainly describes the sequelae of a ruptured, potentially non-healing eardrum as opposed to the acute occurrence of earache itself. (This is referred to as serous otitis media in Western medicine.) And kidney yin vacuity with toxin accumulation likewise describes the sequelae of a ruptured, non-healing eardrum in a constitutionally yin vacuous child or geriatric otitis media. Therefore, although these last two patterns may be seen in infants and very young children, they are not the most common patterns of acute pediatric otitis media – the patterns that keep parents up at night in sleepless irritation and high anxiety.

My first teacher of Chinese medicine was Eric Tao (Xi-yu) of Denver. When lecturing on pediatrics, Dr. Tao always reiterated that, in infants, there is only one main disease mechanism and that is food stagnation. It is an axiom in Chinese pediatrics that:

Children’s transportation and transformation is not fortified and complete. Therefore, they are easily damaged by food.

Food damage is another name for food stagnation, and transportation and transformation refer to the spleen’s transportation and transformation of both the food and body fluids. This means that infants are susceptible to food stagnation due to inherently weak spleens which do not mature until some time after six years of age. When food becomes stagnant in the stomach, this yin depression hinders the free flow of yang qi. Due to Liu Wan-su’s theory of similar transformation, when yang qi backs up behind this stagnant yin food, it transforms into depressive heat. This transformation into depressive heat is all the more likely in infants because, "children have a pure yang constitution." This means that yang is not well blended with and balanced by yin. Hence yin is not as capable of restraining yang and keeping it under control as in adults.^[4] In addition, the life gate or ministerial fire in infants undergoes periodic cycles of exuberance. This is called "transmutation and steaming." The concept of transmutation and steaming describes the periodic growth spurts children experience which, in infants, are commonly accompanied by emission of heat or fever. Teething is one example of a growth spurt associated with transmutation and steaming and, therefore, commonly fever. When the ministerial fire become exuberant, it may mutually engender any evil heat in the body, such as depressive heat mixed with food stagnation.

Because heat is intrinsically yang and yang tends to move upward and outward, depressive heat does not necessarily stay in the stomach. Instead, it counterflows upward along the channels and network vessels. Because of the close association of the stomach and liver via the control cycle of five phase theory and due to the fact that, in children, "the liver commonly has a surplus," stomach heat may be transmitted to the liver and from thence to the gallbladder and triple burner channels.^[5] The gallbladder and triple burner channels encircle the ear. Thus heat following the gallbladder channel upward may arrive at and congest in the bone-walled cavity of the ear, steaming and fulminating, transforming toxins and pus. Additionally, heat in the stomach may also be transmitted to the large intestine channel since both channels together form the unit of the yang ming. A branch of the large intestine network vessel enters the ear. Therefore, depressive heat originating in the stomach may also ascend following the network vessels of the large intestine and thereby arrive at the ear.

Based on the above inter-related theories, we can see that pediatric earaches, especially in infants, may be due to entirely internal causes – stagnant food and depressive heat. Further, stagnant food may especially transform into depressive heat at times of transmutation and steaming when the ministerial fire is naturally cyclically exuberant. However, it is also possible for externally invading wind heat evils to promote the transformation of stagnant food into depressive heat.^[6] According to the larger vision of the life gate or ministerial fire, all the yang in the body is rooted in and connected via the ministerial fire. When wind evils invade the exterior and congest in the skin and muscles, they impede the free flow of defensive qi. The defensive qi is yang by nature. Therefore, if the defensive qi becomes depressed in the exterior, it transforms into evil heat, thus resulting in fever and other such symptoms of evil heat in exterior patterns.^[7] Because this depressed defensive yang is linked to all the other yang qi in the body, it may mutually engender the transformation of yang into evil heat in other related organs and tissues. In infants, these especially include the stomach due to its having "lots of qi and lots of blood" and the liver due to its "commonly having a surplus." Thus externally invading wind evils may mutually engender internal heat.

When there is stagnant food due to spleen vacuity, one must not only transform food and abduct stagnation, one must also fortify the spleen and supplement the qi. If depressive heat has shifted from the stomach and entered the liver and gallbladder channels as well, one must not only clear heat from the stomach but also from the liver and gallbladder. And if there is a dual exterior-interior pattern, then one must resolve the exterior at the same time as treating the interior. In that case, treating the interior means A) to drain any interior repletions, such as stagnant food and internal heat, and B) to supplement any internal vacuities, such as spleen qi vacuity.

Based on my 20 years experience treating pediatric earaches with Chinese medicine, I believe the single best guiding formula for all the above purposes is Zhang Zhong-jing’s Xiao Chai Hu Tang (Minor Bupleurum Decoction). Although this is most commonly categorized as a harmonizing formula, it could just as well be categorized as a dual interior-exterior resolving formula. Radix Bupleuri (Chai Hu) is an acrid, cool exterior-resolving medicinal which also clears depressive heat from the liver and gallbladder. Radix Scutellariae Baicalensis (Huang Qin) clears heat from the lungs, liver, gallbladder, stomach, and intestines without easily damaging the spleen. Radix Codonopsitis Pilosulae (Dang Shen), mix-fried Radix Glycyrrhizae (Gan Cao), and Fructus Zizyphi Jujubae (Da Zao) all fortify the spleen and supplement the qi, while Rhizoma Pinelliae Ternatae (Ban Xia) and uncooked Rhizoma Zingiberis (Sheng Jiang) harmonize the stomach and downbear counterflow, transforming phlegm and eliminating dampness. Therefore, these ingredients supplement the spleen and harmonize the stomach at the same time as they clear depressive heat from the liver and stomach which has also entered and congested in the shao yang channels.

However, in order to treat pediatric earache due to food stagnation transforming depressive heat with possible simultaneous wind heat evils lodged in the exterior, several other medicinals should be added to make this formula more specific to this condition. Since the food stagnation in infants is due to overfeeding with "meaty, animal foods," i.e., milk, Endothelium Corneum Gigeriae Galli (Ji Nei Jin) and Fructus Crategi (Shan Zha) may be added to transform this specific kind of accumulation.^[8] Since pediatric earache is typically accompanied by excessive fluids within the ear, Rhizoma Acori Graminei (Shi Chang Pu) can be added to transform phlegm turbidity and disinhibit the ears, while Pericarpium Citri Reticulatae (Chen Pi) can be added to aid Pinellia and Ginger to harmonize the stomach and transform phlegm and dampness. Since heat steaming within the bony box of the ear may transform toxins and since there may be the presence of simultaneous externally contracted wind heat evils, Flos Lonicerae Japonicae (Jin Yin Hua) and Fructus Forsythiae Suspensae (Lian Qiao) may be added to strengthen this formula’s ability to clear heat and resolve both toxins and the exterior. Since pediatric earache is characterized by pain and, "if there is pain, there is no free flow," Radix Ligustici Wallichii (Chuan Xiong) may be added to move the qi and quicken the blood in the area of the head traversed by the shao yang, thus stopping. In that case, Ligusticum may be seen as both an assistant and guiding medicinal. In addition, Radix Angelicae Dahuricae (Bai Zhi) may be added because of its ability to stop pain and disinhibit the clear orifices, especially in the head, as well as disperse swelling and out-thrust pus.

Based on my experience of using variations of this formula to treat scores of cases of pediatric earache over the last 20 years, Blue Poppy Herbs now manufactures this formula as a high potency desiccated extract. However, to get the maximum effect from this formula A) it must actually fit the baby’s patterns and B) it needs to be supported by proper dietary therapy. As stated above, the pattern of pediatric earache this formula is designed to remedy is food stagnation with spleen vacuity and depressive heat possibly but not necessarily complicated by external contraction of wind heat evils. In that case, the child typically develops acute ear pain manifest by inconsolable crying, especially at night, possible pulling on or batting at the affected ear, fever, a red face and tongue, hot hands and feet, reddish fingernails, yellow or green nasal mucus, bad breath, a tendency to vomiting of milk or abdominal colic, possible foul-smelling stools, a blue vein at the root of the nose (showing spleen vacuity), and a purple red, engorged vein at the wind gate on the ventral surface of the index finger (showing depressive heat due to food stagnation).

Proper dietary therapy first of all means not overfeeding the infant, even with breast milk. Feeding on demand, the current dogma in Western infant feeding, may cause food stagnation even when the food fed is the mother’s breast milk. If solid foods are being fed, then one should avoid all fruit juices, all diary products such as cheese, all chilled and/or uncooked foods, sugar and sweets of all kinds, and anything greasy or fatty, including nut butters. In addition, the parent should seek to identify any specific food allergies, such as to wheat, corn, eggs, or cow milk, and then avoid those foods. This means the child should primarily be fed what is known as a clear bland diet in Chinese medicine. White rice soup is especially beneficial. If dilute enough, this can be used to replace our augment breast milk. For more information on the Chinese dietary recommendations surrounding pediatric earache, please see my book, Keeping Your Child Healthy with Chinese Medicine published by Blue Poppy Press. Since the core mechanism of pediatric earaches is food stagnation due to spleen vacuity, dietary therapy has to be the root treatment of this condition with all other therapies merely supporting and extending the effects of proper feeding.

In terms of first aid adjunctive therapies for helping treat the pain and discomfort of pediatric earaches, small amounts of Borneolum (Bing Pian) and Alum (Ku Fan) can be mixed with plain water to form eardrops both for dispersing inflammation and stopping pain. In addition, acupuncture, electro-acupuncture (with or without insertion of needles), and magnet therapy can all be used for pain relief, with points selected on the basis of the above-stated treatment principles and the main signs and symptoms. Alternating hot and cold compresses to the affected ear may also be used to help alleviate pain and swelling.

Once the pain and fever of acute otitis media have abated, future occurrences may be prevented with a combination of proper diet and prophylactic use of Chinese medicinals. In that case, I most commonly prescribe Xiao Chai Hu Tang with the addition of stomach-harmonizing, stagnation-abducting, dampness-eliminating, and phlegm-transforming medicinals. Depending on the child’s reaction, such a prophylactic formula may be administered for 6-8 months. For instance, I have often used such a protocol to prevent earaches in susceptible children, beginning administration in late September and continuing to the end of April.

While acute pediatric otitis media is distressing enough all by itself, treatment of its underlying disease mechanisms is important in terms of preventing other diseases which may stretch throughout the patient’s entire life. Most chronic diseases begin with some combination of these same disease mechanisms in early life. Food stagnation causes heat, dampness, phlegm, and qi stagnation as well as spleen vacuity, and depressive heat, dampness, phlegm, liver depression qi stagnation, and spleen vacuity sit at the center of most chronic disease processes. Those who understand Chinese medical theory should be able to see how these core disease mechanisms may further allow for or evolve into yin vacuity, yang vacuity, blood stasis, heat toxins, internally engendered wind, and easy contraction of external evils. In my experience, colicky babies are more prone to earaches, and babies with recurrent earaches are more prone to strep throat and tonsillitis. Since 1) earaches, strep throat, and tonsillitis are all usually treated with antibiotics, at least by Western physicians, 2) antibiotics easily damage young people’s spleens, and 3) spleen vacuity is usually at the root of allergies and autoimmune diseases, there is often a close relationship between these conditions, one supplanting the other at different ages and, therefore, stages of development. Thus, I do not believe it is too much to say that treating the main disease mechanisms of pediatric earache may have a salutary effect on a patient’s entire life.

^[1] Wu, Yan & Fischer, Warren, Practical Therapeutics in Traditional Chinese Medicine, Paradigm Publications, Brookline, MA, 1997, p. 577-581

^[2] However, that does not mean that infants may not have a wind heat exterior pattern, just that it is difficult to definitively substantiate that pattern discrimination.

^[3] Scott, Julian, Acupuncture in the Treatment of Children, Revised Edition, Eastland Press, Seattle, 1992, p. 201

^[4] This fact helps explain with infants are so prone to developing fevers and high fevers at that.

^[5] Because the liver is a yin viscus and heat is a yang evil, there is no intrinsic correspondence between the liver and heat. Therefore, it is very common for evil heat in the liver to be exteriorized to it paired yang channel, the gallbladder.

^[6] Readers should keep in mind that it is the defensive qi which protects the exterior of the body from external invasion by pathogens, and the defensive qi issues from the middle burner from which it is upborne to the lungs by the spleen. Therefore, if there is a spleen qi vacuity, the defensive qi is typically vacuous and insecure. This means that the person is more susceptible to invasion by external evils. This helps explain children’s propensity to catching colds and flues and other infectious diseases.

^[7] In fact, a wind heat exterior pattern means that wind evils have invaded the body and resulted in a hot pattern. It does not necessarily imply that the invading wind evils were hot in nature to begin with. Wind evils simply mean unseen air-borne pathogens, and the heat is the body’s response to these pathogens and the disease mechanisms they initiate.

^[8] Massa Medica Fermentata (Shen Qu), Fructus Germinatus Hordei Vulgaris (Mai Ya), Fructus Germinatus Oryzae Sativae (Gu Ya), and Semen Raphani Sativi (Lai Fu Zi) are all better for cereal-caused food stagnation.