Session 2: Infants and Children - Part I · Session 2: Infants and Children - Part I ... syrup or...
Transcript of Session 2: Infants and Children - Part I · Session 2: Infants and Children - Part I ... syrup or...
WHMF314
www.endeavour.edu.
au
Session 2:
Infants and Children - Part I
Naturopathic Medicine Department
© Endeavour College of Natural Health endeavour.edu.au 2
Overviewo Infants & Children
• communication
• dosage, dosage forms
• compliance
o Acute conditions
• coughs
• earaches
• colic
• colds and flu
o Case studies to demonstrate clinical management and
herbal prescriptions for these conditions
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Reference Text
o Santich, R. & Bone, K. (2008). Healthy children:
Optimising children’s health with herbs. Warwick
QLD: Phytotherapy Press
© Endeavour College of Natural Health endeavour.edu.au 4
Communicationo Gather your information
• ask parent questions to answer for child (include child)
• direct appropriate questions to child
• get down at the child’s level e.g. at the toy box
• ask them how they feel and closely observe
• make note of their replies “in their words”
• child friendly stickers/stamps on the dispensed medicine
o Having a sick child can be very stressful
• build child and parent’s trust
• listen to all they have to say
o Know limitations and refer appropriately
• a mild illness can become serious / life threatening
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Dosage Formulas
o Ausberger’s weight rule
• based on weight, accounts for faster metabolism in children
• (1.5 x weight in kg + 10) is % of adult dose
• E.g. child weighs 20 kg
– (1.5 x 20) + 10 = 40% of adult dose
o Clark’s basic rule
• (weight in kg ÷ 67) x adult dose = child’s dose
o Young’s rule
• (age in years ÷ (age+12)) x adult dose = child’s dose
o Fried’s rule for young infants (up to 2 years)
• (age in months ÷ 150) x adult dose = child’s dose
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Dosageo Rule of thumb
• young babies
– 1/2 mL tid - 10 drops
– check actual measure of ‘drops’
• 1-2 years
– 1/4 adult dose - 1 mL tid
• 2-8 years
– 1/3 to 1/2 adult dose
– keep in mind strength as well as weight
• puberty onwards
– full adult dose - 5 mL tid
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Dosage Forms
o Bath
o Topical
o Infusions e.g. diaphoretics
o Glycetracts - especially Althaea officinalis (marshmallow)
o Liquid extracts
• with flavouring, syrup or juice (dark grape juice).
• eye dropper squirt into back of mouth.
o Jellies
o Tablets (remember to adjust dosage) - crushed in honey
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Herbs For Breastfed Infants
It is commonly suggested to administer breastfed neonates
via mother, however:
o Lack of information as to dose required for mother to
achieve adequate transfer
o Lack of pharmacokinetics studies
o Conventional medicine does not rely on this practice
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Herbs For Breastfed Infants
o Most phytochemicals and drugs transfer into breast milk by passive diffusion.
o Rate of transfer influenced by:• Stage of lactation
• Chemical characteristics of drug or phytochemical
• Concentration drug/phytochemical reaches in blood
• Composition of the milk (water, lipids, protein content and pH)
o Balance between herbal dose and elimination rate in mother ultimately determines maternal blood and milk levels.
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Herbs For Breastfed Infants
Colostrum
o First 2-3/7 after birth
o Epithelial cells lining alveoli have open junctions – both
small & large molecules (e.g. proteins) are easily
transferred by paracellular diffusion
o Concentration in maternal blood essentially controls
drug/phytochemical transfer into colostrum
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Herbs For Breastfed Infants
o Milk secretion 3-4/7 after birth• Gaps between epithelial cells close
o Major pathway for passive diffusion of drugs/phytochemicals is transcellular
o Mature milk of relatively stable composition produced 2-3/52 after birth• Major components are ions, proteins, lipids
• Lipid fraction important as lipid soluble chemicals may dissolve in liquid droplets as they form in alveolar epithelial cells and thereby co-secreted
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Example study on transfer of
phytochemicals into breast milk
Rhein- anthraquinone in Rheum officinale (rhubarb root) and Cassia acutifolia (senna)
o Several studies have shown that rhein appears in blood, with a rapid rise after ingestion, then decline
o Excretion of rhein (from Cassia acutifolia) into breast milk investigated in 100 milk samples from 20 postpartum women
o Rhein concentration in milk samples from every lactation during post-dose 24 hours measured, following daily doses of 5 g of senna (15 mg rhein) for 3 days
Continued next slide…
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Rhein in breast milk study continued…
o Values varied from 0 - 27ng/ml
o < 10ng/ml in 94% of samples
o Median values demonstrate 0.007% of rhein intake
excreted into breast milk
o No abnormal stool consistency in breastfed infants
o Conclusion: unlikely that normally recommended doses
of most herbal medicines taken by mother will have
therapeutic effect in infant (Santich & Bone, 2008)
o NB Herbs contraindicated in breastfeeding remain
contraindicated
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Complianceo Poor compliance is a significant issue (non compliance
for conventional medicine ranges from 25 – 60%) with a
peak during adolescence
o Palatability is important
o Your materia medica may be limited by what children will
actually take!
o Children are more partial to sweet taste
o Parent’s attitude often dictates child’s willingness to take
remedy
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General Considerationso Child’s vital force is powerful self-correcting mechanism
o Child’s recovery rate greater than adult
o Children generally are energetically warmer than adults
o Most common condition acute infection (‘hot’ in nature)
o Cooling remedies often important (e.g. diaphoretics and
bitters)
o Occasionally mild illnesses can quickly become serious
o Most prominent systems
• Respiratory, gastrointestinal, immune
o Average child experiences 5 to 6 respiratory infections
per year (usually mild)
o This is normal & of benefit in developing immune system
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Vitality Naturopathic philosophy posits allowing / supporting the
body to heal itself. Conventional medicine also in line with
this position:
• Fever suppression not advocated (see next slide…)
• No treatment needed for mild croup with cough only https://www.rch.org.au/kidsinfo/fact_sheets/Croup/
• Antibiotics for otitis media not routinely prescribed/recommended
Antibiotics modestly more effective for treatment of otitis media,
compared to no treatment (adverse effects 4%-10% of children)
(Coker, Chan, Newbury & Limbos 2010)
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Fever o Body temperature >38º C
o Inform parents of the protocol of fever management as
per Royal Children’s Hospital which reassures them that
the fever seen in common childhood infections is not
harmful, helps the body's immune system fight off the
infection and states that there is no advantage to
lowering child's fever except for comfort.
• Paracetamol should not be administered for pain, but may be
used for pain associated symptoms
https://www.rch.org.au/kidsinfo/fact_sheets/Fever_in_children/
http://www.rch.org.au/kidsinfo/fact_sheets/Febrile_Convulsions/
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Fever
ANY infant or neonate under 8 weeks
old presenting with a fever must be
sent to emergency department
irrespective of severity or duration of
fever
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Diaphoretic teaso YEP
• Equal parts: Achillea millefolium (yarrow), Sambucus nigra (elder
flowers), Mentha piperita (peppermint)
o Weiss:
• Equal parts: Sambucus nigra (elder flowers), Tilia spp. (lime
blossom), Matricaria recutita (chamomile flowers)
o Directions:
• 2-3 teaspoons dried herb to 250ml almost boiling water
• Leave to infuse for 10 minutes
• Take as soon as possible and as warm as possible
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Immunityo Contributions to a weakened immunity can include:
• Breast or bottle fed
• Diet
• Caesarean section or vaginal birth
(Jakobsson, Abrahamsson, Jenmalm & Harris, 2014)
• Having parents who smoke
(Al-Sayed & Ibrahim, 2012)
o Importance of wholesome diet as preventative strategy
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Treatment Considerations
o In treating children be cautious as to when to treat
exclusively or when to recommend they seek medical
treatment or advice.
o In chronic conditions, realistic treatment goals may be to
reduce the need for pharmaceutical intervention over
time as herbal and naturopathic treatment takes hold.
o Application of the therapeutic order in restoring health for
the child…
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Naturopathic Therapeutic Ordero 1. Establish the Conditions for Health
By addressing the Determinants of Health:
a) Identify and remove disturbing factors (obstacles to cure)
b) Institute a more healthful regimen
o 2. Stimulate the Vis Medicatrix Naturae
o 3. Tonify Weakened Systems(Including constitutional and family weaknesses)
o 4. Correct Structural Integrity
o 5. Address Pathology: a) Natural Substances
b) Pharmacologic or Synthetic Substances
o 6. Suppress or Surgically Remove Pathology
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Assessment of the child
o Use the resource “When should I worry?- your guide to
Coughs, Colds, Earache & Sore Throats” as a review of
the common childhood illnesses for children over six
months old.
• Signs and symptoms
• Usual course of the illness
• Signs and symptoms which warrant concern and are signs of
serious illness
http://www.whenshouldiworry.com/view-booklet.php
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Herbal Treatment and Prevention of Infection
o Immune enhancing herbs (e.g. Echinacea spp.,
Andropgraphis paniculata, Astragalus membranaceus).
o Diaphoretic herbs (e.g. Tilia spp.) to focus immune
function, plus warming herbs (e.g. Zingiber officinalis).
o Support area, organ, system that infection is located in
(e.g. expectorants for lung infections).
o Antibacterial herbs where appropriate (e.g. Agathosma
betulina for UTIs or Melaleuca alternifolia for skin
infections).
o Antiviral herbs as appropriate (e.g. Hypericum
perforatum for enveloped viruses, Melissa officinalis
topically for herpes virus).
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Otitis media
o One in 4 children will have at least 1 episode of acute
otitis media (AOM) by age 10 years.
o AOM results from infection of fluid that has become
trapped in the middle ear.
o The bacteria that most often cause AOM are
Streptococcus pneumoniae, Haemophilus influenzae,
and Moraxella catarrhalis.
o Need to differentiate AOM from otitis media with effusion
(OME)
• Although fluid is present in the middle ear in both conditions, the
fluid is not infected in OME as is seen in AOM patients.
(Dickson, 2014).
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Acute otitis media (AOM)
o AOM is diagnosed on the basis of acute onset of pain
and fever; a red, bulging tympanic membrane; and
middle ear effusion.
o Medical management : analgesia (paracetamol or non-
steroidal anti-inflammatory drugs).
o Antibiotic therapy is minimally effective for most patients
• Most effective for children < 2 years with bilateral otitis media
and for children with discharging ears.
• National guidelines recommend antibiotic therapy for Indigenous
children
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Otitis media with effusion
o Otitis media with effusion (OME) is diagnosed as the
presence of middle ear effusion (type B tympanogram or
immobile tympanic membrane on pneumatic otoscopy)
without AOM criteria.
• Well children with OME with no speech and language delays can
be observed for the first 3 months; perform audiological
evaluation and refer to an ear, nose and throat (ENT) specialist if
they have bilateral hearing impairment > 30 dB, or persistent
effusion.
• Children with effusions persisting longer than 3 months can
benefit from a 2-4-week course of amoxycillin.
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Chronic suppurative otitis media
Chronic discharge through a tympanic membrane
perforation.
o Medical management:
• regular ear cleaning (dry mopping or povidone-iodine [Betadine]
washouts) until discharge resolves, topical ear drops (e.g.
ciprofloxacin);
• audiological evaluation, and ENT review.
(Gunasekera, O’Connor, Vijaasekaran & Del Mar, 2009).
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Fig: I Tympanic Membrane
A, Normal TM. B, TM with mild bulging.
C, TM with moderate bulging. D, TM with severe bulging. (Hoberman, 2013)
Lieberthal A S et al. Pediatrics 2013;131:e964-e999
©2013 by American Academy of Pediatrics
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Otitis Media
o Anatomical differences between infant & adult
Eustachian tubes promotes development of conditions in
children.
• Infant Eustachian tube:
– relatively short, making reflux more likely
– more horizontal, less efficient muscular action of
tensor palatini that opens the tube
– softer with more compliant cartilage which
predisposes to collapse
– has a smaller lumen more readily occluded by
mucosal inflammation
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NPS guidelines for treatment of
otitis media o Otitis media will often get better by itself in a few days as the
body’s immune system can take care of the infection without
any treatment.
o Most children older than 2 years won’t need antibiotics
treatment, e.g. infection will clear up by itself in a few days.
o However, many children younger than 2 years may need
antibiotics to treat the infection.
o Antibiotics won’t help relieve child’s ear pain.
• Research shows 6 out of 10 children will have no ear pain after
the first 24 hours without any treatment antibiotic or analgesia
http://www.nps.org.au/conditions/ear-nose-mouth-and-throat-disorders/ear-nose-and-
throat-infections/ear-infection-middle/for-individuals/medicines-and-treatments
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Otitis Media ...herbal treatment o Anti-catarrhal
• Nepeta cataria (ground ivy)
• Euphrasia officinalis (eyebright)
• Solidago virgaurea (golden rod)
o Immune enhancing
• Echinacea spp. (echinacea)
• Pelargonium sidoides (pelargonium)
o Ear infection specific
• Verbascum thapsus (mullein), infused flower in oil often
combined with garlic (1 - 3 drops)
o Treatment of URTI
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Prevention of Otitis media
o Breastfeeding for at least 4 to 6 months reduces episodes of AOM
and recurrent AOM
o Dose response: some protection from partial breastfeeding and the
greatest protection from exclusive breastfeeding through 6 months
of age.
• Any formula used in the first 6 months of age significantly
associated with increased incidence of OM
o Eliminating exposure to passive tobacco smoke
o Bottles and pacifiers have been associated with AOM.
• Avoiding supine bottle feeding (“bottle propping”) and reducing
or eliminating pacifier use in the second 6 months of life
(Lieberthal, Carroll, Chonmaitree, Ganiats & Hoberman, 2013)
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Otitis Media.
o Research on a herbal eardrop was associated
with significant benefit:
• In a trial of 103 children aged 5-18 years with AOM,
infused oils of Allium sativum (garlic), Verbascum thapsus
(mullein), Calendula officinalis (calendula) and Hypericum
perforatum (St John’s wort) significantly reduced ear pain.
• Effect was comparable to anaesthetic ear drops.
(Sarrell, Mandelburg & Cohen, 2001)
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Otitis Mediao An RCT of 171 children with OM studied an eardrop
containing Allium sativum (garlic), Verbascum thapsus
(mullein), Calendula officinalis (calendula), Hypericum
perforatum (St John’s wort), Lavandula officinalis
(lavender) and Vitamin E.
o The trial had 4 treatment arms including A) the herbal
eardrop, B) the herbal eardrop plus topical anaesthetic,
C) oral amoxicillin with the herbal eardrop or D) oral
amoxicillin with a topical anaesthetic.
o Reduction in pain was greater in the herbal eardrop
groups than in the respective control groups.
(Sarrell, Mandelburg & Cohen, 2001)
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Case 1
o A 3 year old child is brought in by a parent with a “cold”
that started 13 days ago. The child has a runny nose
with thin green/yellow discharge and a “chesty cough”.
The child plays happily at the toy box while you speak to
the parent. The parent says child had fever for 2 days at
start of cold and was off her food but now appetite is
back to normal.
o What examinations are appropriate?
o What is your clinical management?
o Herbal prescription
o Other advice, recommendations, referral?
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Case 2 o At the first post partum visit for a mother that you have
been treating during her pregnancy, when asked about
her baby the mother happily recounts that all is going
well, except baby has a slight runny nose. The baby is
breast feeding during the consultation and engaging with
the mother. She asks whether you can give the baby
anything to “boost the baby’s immune system”. You ask
to examine the baby - there is no rash, no swollen
glands, throat appears normal, temperature is 38.6º C.
o What is your management of this baby?
o What would you prescribe for the baby or the mother?
© Endeavour College of Natural Health endeavour.edu.au 38
Case 3 o 2-year old child presents with cold symptoms for the last
5 days. He has a runny nose and sits on his mother’s lap
instead of playing with the toys as he usually does.
o On examination, which is a struggle as he is reluctant to
let you take his temperature or examine his ears, he has
a temperature of 39.1 and bilateral red tympanic
membranes with no bulging
o What is your clinical management?
o What is your herbal prescription?
o Does this patient need medical referral or
pharmaceutical medication?
o When do you next need to review?
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Neonate Colic o Diet
• In breast fed babies, a low allergen maternal diet avoiding cow’s
milk and dairy food for at least 2 weeks to test efficacy
• Bottle fed babies: formulas based on partially hydrolyzed whey
proteins with prebiotic oligosaccharides effective
(Savino, Ceratto, De Marco & Cordero di Montezemolo, 2014).
o Lactobacillus reuteri reduces symptoms of infantile colic(Savino, Ceratto, Poggi & Cartosio,2014).
o Maternal Stress
• A number of studies link increased maternal stress / anxiety with
increased colic risk (Santich & Bone, 2008).
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Herbal treatment of Colic
o Foeniculum vulgare (fennel), Matricaria recutita
(chamomile) & Melissa officinalis (lemon balm) may help
calm the infant & reduce abdominal distension (mice)
(Savino, Cresi, Castagno, Silvestro & Oggero R., 2005)
o Foeniculum vulgare (fennel) seed oil emulsion superior
to placebo in RCT
(Alexandrovich, Rakovitskaya, Kolmo, Sidorova & Shushunov., 2003)
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Dyspepsia/Reflux
o Iberogast® indicated for functional dyspepsia
o May be useful for reflux and colic in infants
o Easy to administer
(Ottillinger, Storr, Malfertheiner & Allescher, 2013; Perez, Youssef, 2007).
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Pelargonium sidoides
o Also known as umckaloabo, is a member of the
Geranium family and is native to South Africa.
• “Umckaloabo" is derived from the two Zulu words, "umkhuhlane"
(fever and cough-related illnesses) and "uhlabo" (chest pain
related to pleurisy)
• Traditionally used for centuries for the treatment of respiratory
diseases, diarrhoea, dysmenorrhea, and hepatic disorders
o An aqueous formulation of the roots of Pelargonium
sidoides, called EPs 7630®, has been examined in
clinical trials as a potential treatment for bronchitis
(acute) acute pharyngitis (acute non-group A beta-
hemolytic streptococcus tonsillopharyngitis), and the
common cold.
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Pelargonium sidoides
Relevance & Safety
o Specifically indicated for children.
o Safety in children: safe when used orally and
appropriately, for short periods.
o A specific extract (Umckaloabo, EPs 7630®, Schwabe
GmBh, Germany) in doses of 3mL per day (20 drops)
has been safely used in children aged 6-10 years for up
to seven days.
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Class Activity
o Break into 4 small groups. Each group will be allocated
one of the Phytomedicine papers on Pelargonium.
o Critically review and present a summary to the class. Tahana, F., Yamanb, M. (2013). Can the pelargonium sidoides root extract EPs® 7630
prevent asthma attacks during viral infections of the upper respiratory tract in
children? Phytomedicine 20,148–150
Matthys, H., Kamin, W., Funk, P., Heger, M. (2007). Pelargonium sioides preparation
(EPs ®7630) in the treatment of acute bronchitis in adults and children.
Phytomedicine 14 (SV1) 69-73.
Haidvogl, M., Heger, M. (2007). Treatment effect and safety of EPs® 7630-solution in
acute bronchitis in childhood: Report of a multicentre observational study.
Phytomedicine 14 (SVI) 60–64
Taofikat, B., Agbabiakam T.B., Guo, R., Ernst, E. (2008). Pelargonium sidoides for acute
bronchitis: A systematic review and meta-analysis. Phytomedicine 15, 378–385
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Withania somnifera
o General tonic, adaptogen, antiinflammatory, mild sedative, nervine tonic, immunomodulatory, antianemic, antioxidant, haemopoietic.
o It is commonly used in emaciation of children –considered the best tonic for children:
• traditionally decocted in milk
• promoting growth in children
• increasing serum iron in children
• inflammatory conditions e.g. asthma, bronchitis
• promoting learning & memory
• enhancing immune function
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Withania somniferao Early research supports a role for Withania somnifera in
children:
• In a randomised, double blind, placebo-controlled trial - milk
fortified with Withania (2g/day of herb for 60 days) significantly
increased mean corpuscular haemoglobin, serum albumin,
blood haemoglobin, serum iron, body weight & strength of hand
grip in children aged 8 to 12 years
• Placebo group did not show any significant change or tendency
to change
(Venkataraghavan et al.,1980),
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Whooping Cough / Pertussiso Recognise symptoms - usually starts with cold –like
symptoms, runny nose and dry cough, which last for
about one week.
o Followed by development of a more definite cough,
which may last for many weeks. The cough comes in
long spells and often (but not always) ends with a high
pitched 'whoop' sound when they breathe in.
o Recap the infective nature of the disease and treatment.
o NB. Especially dangerous in babies under 6 months of
age - usually requires admission to hospital.o http://www.rch.org.au/kidsinfo/fact_sheets/Whooping_cough/
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Whooping Cough Treatment
Role of herbalist includes:
o Relieving and minimising the “100 day cough” that
follows the infection with:
• Immune system support
– Immune stimulants Echinacea spp.
– Antimicrobial/antibacterial – Garlic, Thyme, Pelargonium
• Cough relief: Demulcents, Antitussives, Expectorants
– Prunus serotina, Inula helenium, Plantago lanceolate
• Drosera longifolia (sundew) - specific for whooping cough
(antispasmodic, relaxing expectorant, demulcent)
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References
Al-Sayed, S.M. & Ibrahim, K.S. (2012). Second-hand smoke and
children. Toxicology and Industrial Health 30(7), 635-644
Alexandrovich, I., Rakovitskaya, O., Kolmo, E., Sidorova, T., Shushunov, S.
(2003). The effect of fennel (Foeniculum vulgare) seed oil emulsion in
infantile colic: a randomized, placebo-controlled study. Alternative
Therapies in Health and Medicine, 9, 58–61.
Coker, T.R., Chan, L.S., Newbury, S.J., Limbos, M.A., (2010). Diagnosis,
microbial epidemiology, and antibiotic treatment of acute otitis media
in children: a systematic review. JAMA 304(19), 2161-9.
Dickson, G.(2014). Acute otitis media. Primary Care 41(1), 11-8.
Gunasekera, H., O’Connor, T.E., Vijaasekaran, S. & Del Mar, C.B. (2009)
Primary care management of otitis media among Australian children.
Medical Journal of Australia 191(Suppl),S55-9.
Jakobsson, H.E., Abrahamsson, T.R., Jenmalm, M.C., Harris, K. (2014).
Decreased gut microbiota diversity, delayed Bacteroidetes
colonisation and reduced Th1 responses in infants delivered by
caesarean section. Gut 63(4), 559-66.
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References cont’d
Lieberthal, A.S., Carroll, A.E., Chonmaitree, T., Ganiats, T.G. & Hoberman, A.
(2013). The diagnosis and management of acute otitis media.
Pediatrics, 131, e964–e999
NPS MedicineWise. (2012). Conditions: Ear nose mouth and throat
disorders. Retrieved from http://nps.org.au/conditions/ear-nose-mouth-and-throat-
disorders/ear-nose-and-throat-infections/ear-infection-middle/for-individuals/medicines-and-treatments
Ottillinger, B., Storr, M., Malfertheiner, P., Allescher, H.D. (2013). STW5
(Iberogast®) – a safe and effective standard in the treatment of
functional gastrointestinal disorders. Wiener Medizinische
Wochenschrift, 163(3-4),65-72.
Perez, M.E. & Youssef, N.N. (2007). Dyspepsia in childhood and
adolescence: insights and treatment considerations. Current
Gastroenterology Report, 9(6), 447-55.
Royal Childrens Hospital. (2017). Kids Information: Fact sheets–
whooping cough. Retrieved from http://rch.org.au/kidsinfo/fact_sheets/Whooping_cough/
Royal Childrens Hospital. (2017). Clinical Guide: Laryngotracheobronchitis.
Retrieved from http://rch.org.au/clinicalguide/guideline_index/Croup_Laryngotracheobronchitis/
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References cont’d
Royal Childrens Hospital. (2017). Kids Information: Fact sheets–fever in
children. Retrieved from http://rch.org.au/kidsinfo/fact_sheets/Fever_in_children/
Royal Childrens Hospital. (2017). Kids Information: Fact sheets–febrile
convulsions. Retrieved from http://rch.org.au/kidsinfo/fact_sheets/Febrile_Convulsions/
Santich, R. & Bone, K. (2008). Healthy children: Optimising children’s health
with herbs. Warwick, QLD: Phytotherapy Press.
Sarrell, M., Mandelburg, A. & Cohen, H.A. (2001). Efficacy of naturopathic
extracts in the management of ear pain associated with acute otitis
media. Pediatrics, 111(5),574-579. Retrieved from https://archpediatrics.com
Savino, F., Cresi, F., Castagno, E., Silvestro, L., Oggero, R. (2005). A
randomized double-blind placebo-controlled trial of a standardized
extract of Matricariae recutita, Foeniculum vulgare and Melissa
officialis, (ColiMil), in the treatment of breast-fed colicky infants.
Phytotherapy Research 19, 335–40. doi: 10.1002/ptr.1668
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