Moshe Heller & Stephen Cowan

Phlegm – Etiology pathology and treatment Moshe Heller

Hi, my name is Moshe Heller. First I’d like to thank the American Acupuncture Council for hosting this show, and providing this really wonderful platform for writing information.

I’d like to start talking today, and today’s lecture would be, I will talk a little bit about pediatric phlegm, or phlegm in general. I want to just have a short discussion about etiological factors, pathology, and also the treatment. Since phlegm is actually a very, very common thing nowadays because of, as we know, a lot of … The flu is very common and upon us. As disease progresses, I see many children presenting with phlegm presentations in the past few weeks.

Let’s start. I think the slides are on, and you’re seeing it. The first thing I’d like to just talk about is that … Why do children actually have phlegm, or tend to have phlegm? There’s a famous saying that children produce phlegm very easily, and there’s a few reasons for that.

It all starts with the fact that, actually, children are born with very weak spleens. We assume that, at the beginning of their life, they will always have spleen vacuity. That presents with their tendency to have difficulty digesting, also having very soft stools. That’s a normal thing for them, and that’s a very clear sign their spleen is deficient. Therefore, when you have a spleen deficiency, dampness can easily accumulate and therefore transform into phlegm.

Also there’s another saying that the exterior of children is not secure, and they contract pathogens very easily. WHen the child contracts a pathogen, it influences the way that the lung functions, and the spleen. Therefore, also, the end result could be an accumulation of phlegm, or dampness and then phlegm.

There are a few other supportive factors to the production of phlegm, and one of them has to do with … What I see very commonly now is that the feeding schedule is not as … Parents tend to feed babies on what we call “on demand”. Therefore their scheduling of feedings are random, and sometimes cause this eating on various times, and end up a lot of times overeating. That in itself can also cause an issue with or become a burden on the spleen, and therefore produce more phlegm.

Also, as the children grow, and we start to introduce new foods, a lot of times wrong foods can be presented to them. Meaning either they’re too cold or difficult on the digestive system, and that could be because one of the most common thing is introducing fruits earlier on, or too early. As we believe in Chinese medicine, that fruits are cold and therefore can really burden the spleen, also.

There’s also the issue of formula. I think that sometimes the formula is very heavy and is actually over rich, and therefore not so easy to digest. A lot of children, once they’re put on formulas, actually start developing phlegm. It’s a very interesting thing to watch, because we have then the issue of, what to we do if there’s no other sources of food, and we have to look at different formulas as solutions?

I also want to mention one other thing that’s really commonly seen in my office is that a lot of times antibiotics are given inappropriately, meaning that … Antibiotics definitely have a place and a time to be used, and they are very important. Nonetheless, if they’re used inappropriately, they can produce a dampness very easily because of their nature. As we know, from a Chinese medical perspective, antibiotics are cold and bitter, and therefore they are hard on the spleen. If we have a cold condition, and it’s a cold exterior condition, and we give out antibiotics, the end result will be that there will be some phlegm developing, or damp and then phlegm.

How do we diagnose? How do we know that there is phlegm in the body? Sometimes in children the easiest way is that we see it. As we saw in the first picture of the slides, sometimes it’s very visible, but sometimes it isn’t. If there’s no discharge, there are other telling signs that are important to realize.

One thing ends up as a result of this, especially if the phlegm is stuck in the sinuses, the child becomes a mouth breather. A lot of times we’ll see that their lower lip is a little saggy. Especially if they’re trying to concentrate, you’ll see that their lower lip opens and falls down, and it doesn’t shut down. A lot of times it will also result with some more drooling, or a tendency to drool, heavier if they’re at the teething age.

We have this drooped lower lip, and then mouth breathing. Then we can hear them breathing a lot of times. Another telling sign is snoring at night. Snoring at night usually indicates there’s something that’s blocking, and that phlegm is one of the causes of snoring in kids. Mouth breathing, heavy breathing, or snoring at night, those are all really strong signs.

Of course, palpating the lymph glands is a very important diagnostic procedure in children, because if the lymph glands are swollen, that’s a really strong sign that there is some phlegm accumulating, and a very particular type of phlegm, which we’ll talk in a second. Then, also, the actual history itself of the disease. If there’s chronic sinusitis, or chronic ear infection, or tonsillitis, all these are signs that maybe there’s this phlegm that’s lingering, and is a part of the pathology of the disease.

Another thing that’s really important to use as a tool is listening to the lung sounds. That’s something that, if you’re seeing children, you should probably have a stethoscope with you, because listening to the lung sounds can help in your diagnosis, another sign that can help you in the diagnosis of the patient.

For example, if you hear wheezing when you listen to the lung, you know that that is a constriction of the bronchials. That means that there’s Chi stagnation. But, if you hear crackles, crackles are the sounds like little balloons popping, that is a sound that there is phlegm in the lung. I use it as a diagnostic technique. I listen to the lung. If I hear those crackles, I know that I’m going to need to clear phlegm from the lung.

I want to go over two patterns, this is diagnostic patterns, that are very common in children. The first one I want to discuss is accumulation disorders. We discussed this many times before, but I’m just want to remind you that a lot of times accumulation disorders are the reason that children are presenting with phlegm.

What it is is that … It’s like food stagnation in adults, but its difference is that this could be just from either overeating or eating things that are very difficult for them to digest, and then that accumulates in the stomach and creates this heat and phlegm. The heat symptoms manifest with these red cheeks that are there all the time. This is heat rising from the stomach, and you’ll see these little, almost like stop lights, with the two red cheeks. They’re very distinct. It’s a sign that the digestion is a little overheating and stagnant.

Of course, that will also affect their … They’ll be a little more cranky and irritable, and maybe have difficulty falling, or staying, or waking up frequently. These children don’t sleep as well because something’s not digesting well.

Of course, once these fluids go up and stagnate, they can cause phlegm to accumulate. Then you’ll see this green nasal discharge, exactly like you saw in the first picture. Then you’ll probably see cough involved with it that is very rattly, and maybe some slippery coughs. These are all phlegm signs that come from the accumulation disorder.

When we recognize or diagnose accumulation disorder as the source, we always need to think of Si Feng as the treatment points. Of course, Stomach 36, Stomach 25, and CV-12 are also really important to help, and San Jiao 6, which really helps to move the Chi and resolve the blockage in the digestive system. These are all really important points, but the main treatment point will be Si Feng.

Then the formula that you might be considering has to do with helping the digestion. I have a great formula that’s based on Bao He Wan in my new motion line. I have a website that will be at the end of the slideshow. You can log on and look at digest. It’s a really fantastic formula for supporting the digestive system in situations just like that.

The other aspect is lingering pathogenic factors. Lingering pathogenic factor, a lot of times either cause phlegm or are the phlegm itself. When we diagnose lingering pathogenic factors, we usually have three types or three syndromes under that. One is more of a deficient kind that’s a little more rare, and it involves spleen Chi deficiency. The other one is called retention of phlegm, and retention of very thick phlegm.

We’ll go over the last two just to remind you how we diagnose them. When we only have retention of phlegm, usually you’ll see that there’s this recurring infection, and it can be anywhere from the sinuses, to the throat, to the chest, to the ears. There’ll be a lot of phlegm or discharge from the nose, or cough with a gurgling or rattling sound. There’ll be mouth breathing, like we discussed earlier. There’s emotional state where they want things, but they don’t really want them. They’ll say, “I want this,” but when you give it to them, they’ll throw it away. That’s a very typical sign of that. Then, also very choosy, and wanting only sweet or white foods.

Sometimes you’ll see a manifestation of that phlegm on the stool itself. That’s question we have to ask parents. How does the stool look? Does it change color? Have you noticed any changes in … If there’s this glistening, or it’s a little bit shiny, that’s a sign that there’s phlegm in the stool. Then, of course, enlarged lymph glands, which is really a very important sign for the lingering pathogenic factor.

When it becomes thick phlegm, there’s a lot of the same symptoms. A lot of times the thing that triggers me is that, when I ask, when we discuss the illness history with the parents, they’ll always say a sentence like, “Since their illness, they haven’t been really the same.” The underlying mechanism is that the child’s character is altered or really changed. There’s something either subtly or really more significant change in their character.

Then, that’s very typical of that, when we think that phlegm is becoming so distinct that it actually changes the spirit, or changes … With an adult, we’ll say that there’s phlegm blocking the heart orifices, and then the Shen is not as clear. That’s when we start seeing that in children.

A lot of times there’ll be two other signs that I want to say. They’ll have these energy crashes. They’ll suddenly have periods where they just are really cranky, and they only want to really rest. Also it is sometimes associated with intermittent abdominal pain. These are all signs of the lingering pathogenic factor with very thick phlegm.

The treatment, when you recognize that, is combination of four points, Bai Lao, which is an extra point in the back, UB13, 18, and 20. This is the basic protocol. Sometimes I combine it with the Shao Yang combination of Gallbladder 41 and Triple Warmer 5. Also I will palpate UB43. If it feels very full and excess, I might needle that also.

The main form that I use for that is a combination of Xiao Chai Hu Tang. We’ll talk a little bit about Xiao Chai Hu Tang, because it’s not the first formula that you would think for phlegm, but I found it really helpful with many children, especially with children, to resolve phlegm. I guess because [Ban Xia 00:21:00] is in that formula, but it really is a mild way to resolve phlegm. Helps the children resolve it. I’ve used it many times. You can see that, once Xiao Chai Hu Tang is used in its correct formula, you will see a slow drying of that phlegm, and the symptoms are reduced. I really want you to remember Xiao Chai Hu Tang, especially with kids when they have phlegm.

I want to give a case example that I was treating, actually, a few days ago, last week. There’s this two-year-old boy that came to my office that the parents were saying that was experiencing back-to-back ear infections. Again and again, the ear infections would repeat. Also it always comes with fever and pain. The child really is two years, but still is talking already, and expressing pain in the ear. He mostly tugs and pulls on the left ear, but both ears is something that he’s experienced.

His mother says that everything was normal during pregnancy. The delivery was fine. At the end he needed to be vacuumed, but he was healthy otherwise. Around nine months of age, something around then, she had to stop breastfeeding, go back to work. Although she was giving him formula beforehand as a supplement, at around nine months, around that time, formula was a the only thing she was giving, of course and the introduction of solids.

At that time, there was a lot of dairy products that were introduced. That created a lot of wheezing, or he started to have these episodes of wheezing, almost like asthma. Went to the doctor, the doctor gave steroids in a nebulizer, an inhaler. That really calmed the wheezing, as the mother was reporting.

Then, a few months later, he got another really bad cold. Then that developed into an ear infection, and he was given antibiotics. Since then, it’s been repeated ear infections and rounds of antibiotics. Last round of antibiotics was about three weeks ago. He was given Amaxicillin, and he is currently still complaining of ear infection, although there’s no fevers, which the mother was relieved. She took her to the pediatrician a few days before the appointment, and there was still accumulation of fluids behind the ear drum. The doctor was saying that they may need to consider doing ear plug operation. That’s why they were looking for an alternative way to treat him.

The mother was saying that the baby is a very picky eater, and in the last month they were trying to get him off of dairy, because they thought that that could be a problem, and that’s why he’s having the ear infections, which I agreed. We also agreed that, from now on, they should probably stop wheat.

Bowel movements are two to three times a day. The mother thinks it’s pretty normal, and they don’t seem to be too soft or hard. He doesn’t complain of stomach aches. But, his sleep is not good. He wakes very frequently. He drinks a lot of water throughout the night, and also the mother reports that he’s addicted to the pacifier throughout the day. She’s wanting him to stop, or trying to wean him off of that.

On examination, I found submandibular lymph nodes that were positive or enlarged. His finger vein, which is something that I observed, was very dark, which means heat, and wide. That means that the pathogen is strong, and it’s reached the wind gate. It hasn’t really penetrated extremely deep. Therefore we could address it by resolving it on the [Yan 00:26:43] layers. I’ll explain in a second. Also, when I was examining him, it was clearly that his breathing was heavy and he sounded very congested.

Out of that, I was very clear that his diagnosis was that he had what we call thick phlegm LPF. I believe that it had developed from what we might call a food accumulation, or an accumulation disorder prior to that. I needled the points San Jiao 5 and Gallbladder 41. That is a combination I use for ear infections, because when we address the Shao Yang, it opens up the flow of Chi around the ear. That could be, in itself, the treatment for the ear part of the disorder.

I also added Bai Lao UB13, 18, and 20, as we know, because of the lingering pathogenic factor. I also prescribed Xiao Chai Hu Tang. The first days after the treatment, I got a report that the child was sleeping much better, which was I think a very important sign to see.

I’m running out of time, but I wanted to just mention a few formulas that we usually use for phlegm. Including Er Chen Tang, is an important basic formula for phlegm that we know. Sometimes you can combine that with Xiao Chai Hu Tang. I usually think of Er Chen Tang when I see a spleen deficient at the background of the phlegm accumulation. If there’s spleen deficiency at the background, Er Chen Tang is what I would think for.

Ban Xia Hou Po Tang, another really important formula for phlegm. The difference between that and Er Chen Tang is that Er Chen Tang is more spleen-y, and whereas Ban Xia Hou Po Tang is more liver-y. If the spleen is really deficient and is the cause of the phlegm accumulation, then we can use Shen Ling Bai Zhu San. Or, if there’s an accumulation disorder at the background, Bao He Wan is the choice. As I mentioned, you can check my variation of Bao He Wan in the motion herbs website.

There’s other two formulas I just want to mention that is related to cough. Qing Qi Hua Tan Wan is the famous phlegm heat, or sometimes called Pinellia Expectorant. That clears phlegm heat from the lung. That’s when you have a lot of this cough, which is productive with yellow phlegm. But, if there’s more phlegm dryness, we think of Bei Mu Gua Lou San as the formula for resolving phlegm and dryness.

I think that’s about the time that I have for this presentation. Thank you very much for joining me, and I hope we will meet again in our next session.

Please subscribe to our YouTube Channel ( ) Follow us on Instagram (, LinkedIn ( Periscope ( Twitter ( If you have any questions about today’s show or want to know why the American Acupuncture Council is your best choice for malpractice insurance, call us at (800) 838-0383. or find out just how much you can save with AAC by visiting: