Anthroposophic Approach to Pneumonia

International Expert Recommendation

Introduction

Pneumonia is a serious illness in childhood mainly caused by viruses or bacteria. Viruses were the only identifiable pathogen in 66% children hospitalized in the U.S. for pneumonia [1]. Unfortunately, differentiating viral and bacterial pneumonia remains difficult as neither a consensus nor a gold standard exists [2]. The Bacterial Pneumonia Score (BPS), seems to allow for a good pragmatic classification of viral and bacterial pneumonia, but has the disadvantage of requiring a chest radiograph, which is not needed in routine care [3], and a neutrophil band count that requires labour-intensive manual microscopy counting. New blood-based tools, such as the biomarker combination TRAIL – IP-10 – CRP, hold promise for the future [4, 5] and should be validated e.g. for childhood pneumonia. Decisions arrived at by clinical expert panels remain currently the preferred gold standard to evaluate new diagnostic tools to differentiate between viral and bacterial infections [4].

U.S. guidelines, based on high quality evidence, recommend that antibiotics are not routinely required in the outpatient setting for pre-school children with community acquired pneumonia [6].  A self-limited course of bacterial pneumonia can be fully within the capacity of the immune system of an otherwise healthy individual, depending on the child´s age, with recent attempts in immunomodulation as an alternative to antimicrobial therapy reported in the literature [7].

Regarding an integrative therapeutic approach, in a retrospective case series of 18 adults with community acquired pneumonia managed with an anthroposophic treatment approach, 16 patients were managed effectively without antibiotics, with no complications being observed [8]. In another retrospective case series of 350 children hospitalized for pneumonia, 172 episodes of viral pneumonia and 80 of bacterial pneumonia were identified by using the BPS (in a lightly modified version). The antibiotic prescription rate was 32% overall and 26% for viral pneumonia and 51% for bacterial pneumonia episodes. 6 of 45 patients (13%) initially managed without antibiotics received antibiotics after hospital day 2; all improved rapidly thereafter [9]. Use of complementary medicine was equally high across subgroups. The therapeutic concept explicated below has been applied by anthroposophic physicians for many years in most cases and may be of (additional) use even if antibiotic treatment is necessary.

Symptoms and Diagnosis

Landmark symptoms of pneumonia include:

General symptoms

  • fever
  • chills
  • sickness
  • gray-pale coloration
  • cyanosis, headache
  • abdominal pain
  • tachycardia

Respiration specific symptoms

  • coughing (productive or dry)
  • tachypnoea
  • retractions jugular/intercostal/subcostal 
  • nudging breathing
  • movement of the nostrils

Viral versus bacterial pneumonia – clinical aspects

As described above, viral pneumonia cannot be faultlessly distinguished clinically from bacterial pneumonia. The following table nevertheless provides possible assistance:

[Platzhalter Tab. 1]

Table 1: Differentiation approaches between viral and bacterial pneumonia

Working principles of sustainable integrative therapy

Underlying factors of pneumonia can be addressed by attending to the following aspects:    

Warmth: External applications, warm liquids with thermogenic substances, clothing

Breathing: Inhalations, application of mucolytic substances, chest embrocations, and breathing and speech therapy

Fluids: Sufficient consumption of (warm) infusions, teas, soups etc. (essential for the function of the mucous membranes in the airways).

Diet: Immune supportive nutrition and microbiome care

Psychosomatic aspects: Sufficient time and quiet places for recovery, time for talking (psychological release, reducing anxiety!). Reducing stress and overload, regulating neurosensory input (screens and media), consider emotional and social conflicts   

Biographical and social aspects: Consider biographical and social aspects of the child (family, school, peer-group)

Therapy, behaviour, general recommendations, sick leave

Sick leave should be realized as a pneumonia is a severe disease and the child needs a quiet environment which is necessary to overcome pneumonia.

Parents should

  • take care that the child stays inside at home and in bed as much as possible and necessary
  • reduce screen use
  • avoid active and passive smoking

1. Improving warmth-regulation

a) External applications (see www.pflege-vademecum.org)

  • Ginger chest compress 1 x/d
  • Also mustard compresses are very helpful , especially in cases of bacterial pneumonia, but they should only be applied by people who are experienced in the application of mustard compresses  
  • Thyme linalool 5% oil chest compress 1 x/d for children > 1 year, especially for dissolving mucus
  • Yarrow chest compress (millefolium, herba) when the lungs seem to be too wet (stage of “hepatisation”)
  • Lavender 2% oil chest compress for toddlers; older children 5–10%, at night)    

Rise in fever: Provide with external warmth (warm blankets, warm drinks, appropriate clothing)
Fever plateau: Treatment is only required to lower gently the temperature in case the child is not tolerating high temperatures. Then lemon calf compresses (if feet are warm) may be appropriate or lemon washings.
Fever lysis: Sage (Salvia off., folium) washings, providing with soft external warmth. Rosemary washings, calf-embrocations.

For fever care see www.anthromedics.org/PRA-0815-EN .

b) Warm liquids with thermogenic substances

  • Warm beverages such as elderflowers blossoms and lime blossom tea with honey and lemon help with their mucolytic and warming effect.

c) Clothing

  • Warm, breathable clothing made of wool, especially in the early stages when the child is cold.

2. Improving breathing

a) Inhalations

  • Inhalation with Pulmo/Vivianit comp. amp. WALA: 1 amp. 2–3 x/d 1:1 mixed with physiological saline solution (NaCl 0.9%)
  • Steam with elderflower tea or lime blossom tea: 2–3 x/d for 10–15 min. above a bowl with warm water (about 60–80°C (140–176°F)).
    Please note: Not appropriate for children under 5 years. Children only with one of their parents present.

b) Mucolytic therapy

  • Petasites comp. pilules WALA: 3–7 pil. every 2–3 hours
  • Tartarus stibiatus D6 trit. WELEDA: 1 saltspoon (~¼ tsp.) 3–5 x/d
  • Herb & Honey Cough Elixier WELEDA (also available as Hustenelixier): 1 tsp. 3–4 x/d
  • Warm tea with ginger and/or lemon, or elderflower tea with honey.   

Composition of the medicinal products: Petasites comp.: Abies alba e summitatibus ferm 33d dil. D2 0.1 g; Petasites hybridus e radice ferm 33c dil. D2 0.1 g; Plantago lanceolata e foliis ferm 34c dil. D2 0.1 g. Cough Elixir: 100 g contains 5 g aqueous extract of 0.6 g Althaeae radix / 30 g aqueous Decoctum of: 0.15 g Solanum dulcamara, Stipites sicc.; 0.35 g Marrubium vulgare, Herba sicc. 0.5 g Anisi fructus; 0.35 g Serpylli herba; 2.85 g Thymi herba / Drosera dil. D2 [D2 with ethanol 30% (m/m)] 0.1 g / Extractum Malti 5 g / Ipecacuanha, ethanol. Decoctum (= D1) 0.1 g / Pulsatilla vulgaris dil. D3 [D2 with ethanol 43% (m/m), D3 with ethanol 30% (m/m)] 0.01 g.

c) Chest embrocations and breathing therapy:

  • Chest embrocations (rubbing) with Plantago Bronchialbalsam (bronchial balm, oil for external use) WALA for children > 2 years in the morning and at noon, as well as with lavender 2% oil (toddler; older children 5–10%) in the evening.
  • Chest compresses with warmed beeswax plates.
  •  “Bubbling bottle”: An empty bottle is filled with water. The child tries to exhale through a wide straw slowly but strongly enough to produce bubbles in the bottle.

3. Sufficient fluid/liquids

  • Oral rehydration with warm liquids (like tea, see above)
  • Rectal rehydration (for poorly/non-drinking febrile infants) with suitable rehydration-solutions at body temperature (approx. 37°C or 98.6°F) [10, 11]

4. Strengthen the immune (and pulmonary) system

a) Immune supportive nutrition and microbiome care

  • Wholesome nutrition (more important than isolated vitamins and substances), cooked food, ripe fruits, avoid processed foods, esp. sugar, too many milk products.
  • Cooked food (local farming, organic or Demeter origin is best).
  • Recommended:
    -      fermented milk products (yogurt, sour cream, quark/farmer’s cheese)
    -      boiled root vegetables (carrots, beetroot etc.)
    -      fruits only cooked or steamed (apples, pears)
    -      porridges (by day of the week)
    -      vegetable soups
    -      sourdough-based bread
  • NOT recommended (especially during fever period):
    -      meat
    -      milk and cheese
    -      potato and sweet potato
    -      beans
    -      sugar (sweets etc.)
    -      yeast cakes, bread & pastries

b) Medication 

  • Echinacea/Argentum pilules WALA or WELEDA: 5–10 pil. 3 x/d (see Rhinosinusitis)
  • Ferrum phosphoricum D6 tablets WELEDA: ½–1 tabl. 5 x/d
  • Initially (day 1–3): Pulmo/Vivianit comp. amp. WALA: 1 ml 1x/d s. c. in the upper back, 1:1 mixed with physiological saline solution (NaCl 0.9%), after day three 1 amp. orally, 2 x/d.
  • Children < 7: Bryonia/Aconitum pilules WALA: 5–7 pil. 5 x/d
  • Children > 7: Pneumodoron® 1 WELEDA (also available as Aconite/Bryonia drops): 20 drops daily in ½ glass of water , sip throughout the day.

c) Supporting convalescence (3–6 weeks)

  • After abating of fever children should stay at home for at least 3 days before going out.
  • Roseneisen/Graphit (Rose Iron/Graphite) pilules WALA: 5 pil. 3 x/d for 3–6 weeks

Composition of the medicinal products: Echinacea/Argentum: Argentum metallicum dil. D29 aquos., Echinacea pallida e radice ferm 33d dil. D1. Pulmo/Vivianit comp.: Bryonia cretica ferm 33b dil. D5, Pulmo bovis Gl dil. D16, Tartarus stibiatus dil. D7 aquos., Vivianit dil. D7. Bryonia/Aconitum: Aconitum napellus e tubere ferm 33c dil. D5, Bryonia cretica ferm 33b dil. D7. Pneumodoron® 1: Aconitum napellus dil. D2, Bryonia Dil. D2. Roseneisen/Graphit: Graphites dil. D14 aquos., Rosa e floribus ferm cum Ferro dil. D2.

5. Psychosomatic aspects  

a) Reducing anxiety

  • Parents should take enough time for talking (“psychological release”) to reduce possible anxiety.

b) Sufficient time and quiet places for recovery, time for talking

  • It is essential that the child stays in his or her bed, even if the fever is already gone!  
  • A quiet home environment is a support for the child’s recovery.
  • Neither noisy siblings, nor smartphones, tablets or TV consumption are helpful.  
  • The child should actually be able to withdraw from his or her social life and use his or her energy to recover. 

6. Biographical and social aspects

  • A pneumonia is always a profound experience for both the affected children and the parents of the child.
  • In some cases, it can be helpful to reflect on why the child gets pneumonia at this particular timepoint.
  • Has the child been overburdened within the situation inside the family, at school, in the peer group?
  • If children are given the necessary time to overcome a pneumonia (of course with the necessary medication and therapeutic approaches), they appear to be strengthened and with new energy in their environment months later. This opens a view into the future, so that parents should not only ask themselves why the child has got pneumonia, but also what for?

Pneumonia from the anthroposophic point of view

From a conventional point of view, pneumonia is primarily caused by pathogens (mainly by viruses, bacteria, rarely by fungi). With respect to this approach, a causal therapy is based on reducing or better eliminating the pathogens that cause the disease. For bacteria this becomes possible by antibiotics, which should always be used when necessary (see below). Additionally, it is important to ask about the disposition for infectious diseases. What makes it possible for pathogens to penetrate the organism and to spread out? From a conventional point of view, one reason might be a congenital immune deficiency, which must be examined and clarified. A severe disability or a serious chronic disease can also increase susceptibility to pneumonia. Other aspects may also be important. As one of different examples, the importance of warmth and warmth-regulation should be considered for the disposition for getting infection diseases:

Our body needs to be permeated by our warmth. Lack of warmth, due to inner or outer factors, can predispose to pneumonia. As an internal organ, the lung is connected to the “external world” via the airways. Here, cold temperatures can easily penetrate the core regions of the body. On the other side the lungs are strongly connected to the “inner world”, e.g. to emotions. If we feel cold because the temperatures are too low but also because our surroundings seem mentally and socially cool and unfriendly, our bodies contract. We can experience a feeling of narrowness, especially in the chest region. A child with pneumonia is anxious and feels tightness. Fever during pneumonia is not the cause of the illness but the body's attempt to compensate for the lack of warmth which can be caused by external cold (subcooling) as well as “mental or psychosocial” coldness. One task is to search for the origin of the lack of warmth (however, a detectable immunodeficiency should be excluded beforehand). A chronic, latent lack of warmth can be caused, for example, by the fact that the child is generally dressed too thinly. Another reason can be too little exercise – if the child is sitting in front of the screen for hours instead of playing or is driven around by car instead of riding a bike, running or walking. Hypothermia can also be caused by an early, repeated and unnecessary suppression of fever in any mild infection. The child's “emotional warmth environment” must also be taken into account. A child mentally “inhales the feelings” surrounding him or her in the family. For example, if the parents or adults around the child over a longer period of time interact only coolly and not lovingly, this leads to an increasing inner shivering of the child. According to medical experience, pneumonia frequently occurs in such situations. The detection of pathogens is then only an external sign that the environment is no longer properly invigorated and warmed up.

Pneumonia must always be treated and supervised by a doctor! If bacterial inflammation occurs and if the clinical condition is severe, antibiotics are indicated. Integrative therapy can be carried out as described.

Prevention

The aim of an integrative approach to prevent pneumonia is to strengthen the vital and warmth organization and to reinforce the “rhythmical system”, especially the “breathing middle”.

Parents should

  • try to have the child move actively as often as possible, specially outside in fresh air (strengthening the immune system).
  • create a warm emotional environment
  • have the child breathe through his or her nose as much as possible (also and especially at night, even during sports or other active movements).
  • avoid rooms with too dry air (specially in winter time)
  • spend time in front of screens only as much as really necessary
  • stop passive and active smoking
  • stabilize their child’s vital forces with sufficient sleep and healthy food.

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