Document Type : Clinical Case Reports
1 Assistant Professor of Traditional Medicine, Department of Iranian Traditional Medicine, Faculty of Traditional Medicine, Tehran University of Medical Sciences, Tehran, Iran
2 Ph.D. Candidate of Traditional Medicine, Department of Iranian Traditional Medicine, Faculty of Traditional Medicine, Tehran University of Medical Sciences, Tehran, Iran
Asthma is the most common chronic disease in children and it is highly prevalent in industrialized countries . Today, the number of children with asthma, despite significant progress in controlling the disease and access to different drugs to treat it, is increasing. In 2001, 8.7% of the population suffered from asthma which increased to 9.6% in 2009 and is predicted to increase to 400 million people by 2025 according to Centers for Diseases Control and Prevention (CDC) . More women have asthma as compared to men and yet in children more boys are affected than girls . The disease is caused by temporary and reversible airflow obstruction due to chronic inflammation of the lungs’ airways and sensitivity to different stimuli . According to intensity of the disease, children exhibit symptoms like coughing, wheezing, shortness of breath, or rapid breathing. Common medical treatment of asthma includes control of environmental factors, drug therapy, and patient education to achieve self-care skills . Inhaled corticosteroids (ICSs) are considered as the first choice in the treatment of childhood asthma . Despite the known effect of this drug, recurrent cough and wheezing are seen in 35% of children, such that in a third of the affected children, it leads to persistent asthma . In the recent years, the use of therapeutic methods of complementary and alternative medicine (CAM) has increased, due to the chronic nature of asthma, the side effects of long-term use of chemical drugs, and popular tendency to adopt natural therapies . About 20-30% of adults and 50-60% of children with asthma have used CAM methods at least once . Children, who suffer from asthma with mild to moderate intensity, use these methods more than those suffering from more acute, intense asthma . The most common methods used are breathing techniques, herbal products, homeopathy, and acupuncture though there is no strong evidence of the effectiveness of any of these methods in available studies . Therefore it is important to scientifically evaluate and report traditional and complementary medicine practices and drugs with effective therapeutic effect. The present study is a case study of a 12-year-old boy, whose persistent asthma was treated with the aid of the therapeutic methods of Iranian Traditional Medicine (ITM).
Medical History and Examination according to Modern Medicine
The patient is 12-year-old boy, a known asthmatic case. He suffers from asthma for 4 years before he came for treatment at the traditional medicine clinic. He was a fifth grade student, born and brought up in Tehran till he was ten years old. Two years ago, his family moved him to Mahallat. His weight and height at the time of referral were 50 kg and 155 cm respectively. Onset of symptoms for the disease included a cold and cough and chest pain without shortness of breath. After chest radiography and spirometry test, the paediatrician diagnosed childhood asthma, and treated him with inhaled corticosteroids, ipratropium bromide, as well as in cases of need, salbutamol inhaler. Acetylcysteine was also given for a period of six months, because of the presence of sputum. During these four years, bronchodilator drugs such as cromolyn sodium, nedocromil sodium and montelukast tablets were also administered alternatively, but systemic corticosteroids were not prescribed. Other therapeutic measures have included avoiding allergens (the patient used to have pet birds at home before) and cold air.
The child was born by caesarean delivery, with a birth weight of 3,750 gr and was breastfed. He had food allergies and eczema, as well as positive family history of skin allergies in the mother, asthma in father, and their families. None of the family members were smokers. At the time of the disease diagnosis, the chest X-ray as well as the sputum test showed normal findings. In the spirometry test, his results indicated FEV1 = 75%, FEV1 / FVC = 0.88 respectively. The complete blood count (CBC) represented mild microcytic hypochromic anaemia with plasma haemoglobin electrophoresis indicative of thalassemia minor. The patient was classified as uncontrolled, according to Global Initiative for Asthma (GINA)  classification.
Despite taking the mentioned treatments and avoiding exposure to allergens, the symptoms became worse in the boy. The symptoms worsened upon eating spicy food, saffron, tomato paste, flatulent food, fast food and garlic, as well as on running, laughing, being angry, and when the season turned cold. Guided by a family acquaintance, he was brought to the traditional medicine clinic of the Tehran University of Medical Sciences.
Medical History and Examinations according to Iranian Traditional Medicine
The patient, in terms of the health preservation, respected some six essential principles of ITM. For example, the first principle relates to climate. His residence had been changed from Tehran to Mahallat, the city of Arak, to escape the high environmental pollution. In terms of eating and drinking, he did not respect the correct feeding practices. Wrong nutritional habits of the patient included meal irregularities, eating when not hungry and drinking water before and during meals, not chewing food well, eating fast and eating yogurt with food. Occasionally, when he went to sleep early, he woke up with bad dreams. He played badminton and football irregularly. He had constipation (defecation every other day), but his sweating was natural. Periodically, he had coughing bouts with relatively dense sputum. As for emotional states (mental symptoms), he mentioned anger, anxiety and obsessive compulsive disorder (OCD).
The patient’s inherent temperament was hot and moist, according to the medical history and what the parents reported. In the patient’s general symptoms at the time of referral, he was observed to be feeling hot and heat created trouble. For the little yellow colour of his face, in studies of conventional medicine, no cause has been found. The patient, sometimes when fatigued, had a frontal headache. He had no rhinorrhea. With activities in the morning, he had heart palpitations and mentioned chest pain in the right side, even at rest. On examination, compared to his age, he was average size. He had itching, rashes and hives on his back. Other physical examination was normal.
According to the foundations and principles of ITM, the patient needed therapeutic measures that addressed the six essential principles, strengthened him physically, and reformed his lung temperament with oral and topical drugs.
Measures to Protect Health and Nutrition:
The therapeutic measures began on December 27, 2014. First, about respecting the six essential principles, the patient was provided with needed explanations, emphasizing his need to comply with appropriate dietary practices, proper sleep time (so that he did not sleep immediately after a meal), nap time, maintaining moderate level of physical activity and avoiding anxiety and stress that cause exacerbation of symptoms and asthma attacks. For correct nutrition, the patient was advised to avoid foods containing allergens, and to eliminate dense and slimy meals and foods producing phlegm (cold and wet foods) from his diet. He was also told not to drink cold water.
According to the patient’s temperament and symptoms, oral and topical herbal drugs were prescribed for the purpose of cleaning and adjustment of the lung temperament. To relieve his constipation, some drugs were prescribed as well, because constipation exacerbated existing symptoms caused by the treatment delay. The most important plants and drugs that were used during the treatment for the patient, under different conditions, are given in Table 1, and the contents of the combination drugs are provided in Table 2. In the first visit, he was prescribed Laxita® syrup 5 ml three to four times a day, 5 ml of Echibalm syrup per night and 5ml of Zataria plus syrup three to four times a day. Alongside, mixed powder of maidenhair (Parsiavoshan), anise (Anison), mastic (Mastaki), bitter almond,smearwort (Zaravand Modahraj), nettle seed (Gazane), tragacanth (Katira), and chest massage with asafoetida (Anqozeh) oil were prescribed. On the second visit after six weeks of treatment, despite having suffered from two bouts of cold, the patient had no cough. He reported that his chest pain was much less, and the pressure on his chest about which he complained earlier was much less as well. In a challenge stress test that was performed after 45 days of treatment, FEV1 / FVC = 80% was reported. The frequency of spray use (salbutamol, corticosteroids, ipratropium bromide) was less. His bowel movements had become regular, once to twice daily with a soft consistency, and his mother reported that his skin colour was better than before. According to the mother, there was 90% improvement and the patient believed that his improvement was to a miraculous extent. The patient was advised to continue the Laxita® syrup, mixed powder and asafoetida oil, and the dosage remained unchanged. The patient was advised to take 5ml of Zataria plus syrup with 5ml of Zoufa®syrup twice daily, and if the weather was cold, three times a day. The patient was also advised to add 5ml lavender syrup to Echibalm syrup every night. At this time, in addition to oral drugs and massage with oils, chamomile (Babooneh) fumigation was also added. The dose was 30 gr of chamomile flower per three litres of water, to be inhaled for 20 minutes. At the third visit that was 75 days later, his symptoms were less than before and the patient and his parents were satisfied with the therapeutic measures. The patient was advised to continue with the same dose of Laxita® syrup and mixed powder. He was told to continue with Zataria plus and Zoufa® syrup, to be taken with Bartang distillate and one Eylerzy capsule was added to his list of daily drugs. For food recommendations, he was advised to continue with the previous regimen, and was asked to include barley soup and rumen in his diet. The fourth visit was two months later and the patient was symptom-free, so his drug dosage was lowered. Only black seed (Shooniz) oil rub on the chest, for a week, was added to the treatment.
A follow-up after a year and a half of the patient’s last visit showed that he had no symptoms of the disease. Even during exercise and exposure to cold air, he did not need any medicines.
According to a review that has been published in 2016, so far there are only a few studies with a proper design that have examined the effect of plants on asthma and reported the results properly. But there was evidence that the simultaneous use of conventional and herbal drugs shows better results than using conventional drugs alone . Another review, conducted in the same year, addressed other methods of complementary medicine in addition to medicinal plants. According to this review, studies done on Traditional Indian Medicine, homeopathy, and chiropractic still cannot lead us to a clear response about the effectiveness of these methods in asthma patients. But, in contrast, studies about acupuncture, massage, and osteopathy have been promising . The reviews also failed to prove the effectiveness of yoga as a method of complementary medicine .
ITM, as one of the complementary medicine schools, provides numerous strategies for the prevention and treatment of diseases of different ages, including diseases in children. In ITM, adherence to six essential principles (Setteh-ye-Zarurieah) is important for the treatment of various diseases. One of these six principles relates to the regional climate where a person lives. The best climate to preserve health is temperate air, between hot and cold, devoid of particles and pollutants . In the case presented, before the start of treatment with ITM principles, the patient’s symptoms were so severe that he had to live in Mahallat, away from his family. Mahallat is one of cities with the best climate in Iran, due to being on the hillside. It has greenery, farms of flowers and plants. It is away from malls and industrial plants polluting the air. Mahallat has hot springs, has temperate to a hot and dry climate, and therefore, it is proper for the patient and has helped reduce his symptoms and complaints.
The second of the six essential principles is the principle of eating, drinking and prescription of recipes, which is a main basis for the treatment. Today, also in nutritional sciences, the role of some nutrients in improving or exacerbating diseases has been considered. For example, in asthma, the risk of wheezing is reduced by 50% following consumption of nuts, while olive oil and margarine double the risk . There is no consensus on the effect of dairy consumption on asthma yet. Some studies consider milk to increase the production of mucus and some consider it reduces wheezing [14, 15]. For this patient, according to the symptoms and causes of the disease, dietary solutions were provided on the basis of ITM. He was made to avoid cold and moist food such as cold water, yogurt, buttermilk and some fruits, and was recommended barely soup. This diet cleaned his lungs and relieved cough and chest pain.
Asthma in conventional medicine is largely consistent with rabv and bohr in ITM medicine. According to the rabv approach, in the first step, the Participatory causes of the disease should be excluded . In this patient’s review, except for constipation, there was no other serious problem, so the disease cause was considered to involve the lungs. Also, the presence of dense mucus that obliged the patient to use mucolytic drugs and worsening of symptoms with cold weather, presented the diagnosis of cold and moist distemperament (sue-e-mezaj) of lungs. According to ITM, the treatment base in this case involves Consolidation equilibration of the humors (nozdg) generally and dilution of thick humors (taltif), then dissolution (tahlil) and gradual elimination (tanghieh) of them, indeed clear obstructions (taftih) and finally, adjusting the lung temperament [16, 17].
For Consolidation equilibration, drugs with hot and dry temperament with significant pulmonary efficacy were selected. Intense heat causes moisture to dry up and stay in the lungs, so care was taken to balance against that. For intestinal cleansing, a strong purgative was not prescribed. Diarrhea was carefully and gradually induced, so that in addition to resolving the problem of constipation, evacuation of waste materials was done (cassia, figs, and borage in the diet helped). The drugs were chosen so they would have additional pulmonary effects. For example, figs cleanse the lung mucus and are useful for cough, and borage is useful both for cough and dyspnea . In new studies, some borage species (Borage and Echium plantagineum) also have showed positive effects on reducing the contraction of bronchial smooth muscles . Thymus vulgaris, maidenhair, anise, mastic, bitter almonds, smearwort and nettle seed were the other drugs prescribed in the first session. ITM specifies that, in addition to have dilution, dissolution, phlegm fragmentation and dryness, polishing and clearing obstruction effects, all the drugs mentioned have significant pulmonary effects such as cleansing of the chest, lung and trachea, they are beneficial for rabv and chronic cough too . A study conducted in 2013 showed that the extract of thyme (Zataria multiflora boiss) by reducing IL-4 and the balance of Th1/Th2 had therapeutic and anti-inflammatory effects on diseases with inflammatory responses, such as allergies and asthma . Also, ethanol extract of maidenhair (Adiantum capillus - veneris) inhibits the production of inflammatory mediators .
One method of drug prescription for therapeutic purposes is topical oil that is extracted from various plants. Since drug delivery through the skin is a proper and convenient way that has been used in ITM [21-22], chest rub with proper oil was prescribed, indeed fumigation in this case. Regarding the patient’s significant improvement after the first treatment, the same treatment approach was adopted and similar drugs were used with the above effects. Like any other conventional medicine, ITM considers asthma as a periodic disease, which in the absence of symptoms should not be ignored . Therefore, despite significant improvement of the patient in the first two sessions, the traditional medicine treatments continued for several more months.
Given that asthma is a major cause of school absences across the world that have significant load for patient and society, its correct treatment without any side effects is very important. One of the effective ways to treat this disease is the use of complementary and Alternative medicine, including traditional medicine and herbal drugs. The use of medicinal plants could reduce airway sensitivity and provide better control of asthma. In addition, the therapeutic methods of traditional medicine could prevent the indiscriminate use of common drugs and as a complementary therapy, can be combined with conventional drug therapies. So, conducting strong studies to examine the effectiveness of medicinal plants on the treatment of asthma, particularly in children, is required.
List of Abbreviations
CAM: Complementary and Alternative Medicine
CBC: Complete Blood Count
CDC: Centers for Diseases Control and Prevention
FEV1: Forced Expiratory Volume during 1th second
FVC: Forced Vital Capacity
GINA: Global Initiative for Asthma
ICSs: Inhaled CorticoSteroids
OCD: Obsessive Compulsive Disorder
The authors have no conflict of interest in the publication of this paper.
This article is the outcome of treatment measures by MK, MSP, MSM and cooperated in documenting and writing the article.
The authors of the paper appreciate the cooperation of the patient and his family in providing the history and completing the treatment process.