One Case of Professor ZHAO Jun's Effective Intervention in Children's Height After Menstrual Onsets

LIU Jian-gang (劉建剛), ZHAO Jun (趙 鋆)

Shuguang Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai 201203, China

ABSTR ACT A clinical case of Professor ZHAO Jun's intervention in children's height after menstrual onsets is introduced in this paper, and she believes that regulating spleen and kidney should be paid attention to children in the middle and late stages of puberty. In clinical practice,Pericarpium Citri Reticulatae,Rhizoma PinelliaeandPoria in Erchen Decoction (二陳湯) are used to remove dampness and resolve phlegm, as well as to regulate Qi (氣) and invigorate spleen.Fructus Ligustri LucidiandHerba Ecliptaein Erzhi Pills (二至丸) are applied to invigorate liver and kidney, as well as to regulate Thoroughfare and Conception Channels, so as to achieve the effect of Yin (陰) and Yang (陽) coordination. It has significant efficacy.

KEYWORDS Puberty; Children's height; Regulating spleen and kidney method

Height is one of the important indicators to evaluate children's growth and development,nutrition and health status[1]. At different stages of children's development, height increases at different rates. There are 3 stages of children's height growth: the first growth period lasts from birth to about 3 years old, the stable growth period includes preschool age and early school age, and puberty(the second height growth spurt period). The peak of height increase in puberty is mainly in the period III to IV[2]. The height of girls increases faster than that of boys before menstrual onsets, but after the menstrual onsets, the bone age closes faster and the height growth rate is slower[3,4]. After the menstrual onsets, girls' height growth enters a slow period,and their height generally increases by 4-6 cm and stops[5]. Relevant studies have shown that parents' expectations for future adult height of their children exceed the target height, with boys above 175 cm and girls above 165 cm[6]. This shows that parents have high expectations for their children's height. If there is no reasonable intervention, most children may not reach the ideal height level, and disappointment of parents is self-evident. Therefore,for pubescent girls after menstrual onsets, there is limited room for height growth. How to intervene in height after menstrual onsets has become the focus of parents with unsatisfactory heights.

Professor ZHAO Jun believes that pubescent diseases in children are mostly closely related to the spleen and kidney. The kidney is the congenital origin. Tiangui (天癸) is stored in the kidney. When kidney Qi is sufficient, Tiangui comes into being,and when kidney Qi is deficient, Tiangui will be exhausted. The spleen is the acquired foundation,transporting and transforming essence of food and drink. Sufficient essence of food and drink is transferred to the kidney, filling kidney Qi and kidney essence.Plain Questions(《素問》) records:"For a girl, at the age of 7, her kidney Qi becomes prosperous and her teeth begin to change and her hair grows long. At the age of 14, Tiangui begins to appear, and Conception Channel and Thoroughfare Channel are vigorous in function. Then she begins to have menstruation."Shen's Summary on Obstetrics and Gynecology(《沈氏女科輯要》) records: "Tiangui is female essence, which comes from the Conception Channel. Menstruation indicates menstrual blood, which comes from the Thoroughfare Channel. ThePlain Questionssaid that the reason of Tiangui arriving at the age of 14 is the Conception Channel being unblocked.During this period, the Thoroughfare Channel is vigorous in function, and menstruation also comes into being." The kidney governs bones and stores essence, and the essence produces bone marrow.If the kidney essence is sufficient, the bone marrow is also sufficient, and the bones are strong. Growth,nutrition and function of bones are affected by rising and falling of essence in the kidney. In pubescent children, bones grow rapidly and the bone age accelerates to close. On the basis of syndrome differentiation and treatment in traditional Chinese medicine (TCM), Professor ZHAO Jun effectively intervenes the height of pubescent females after menstrual onsets to delay the closure of bone age at the same time of height growth.Clinical diagnosis and treatment for a pubescent female after menstrual onsets is reported, which was combined with Chinese materia medica in TCM and externally therapeutic interventions, so as to explore and analyze advantages of TCM in intervening the height of pubescent females after menstrual onsets.

CASE INFORMATION

First visit: Miss HE was 12 years old and from Shanghai. Due to menarche on August 2,2016 and lower abdominal distending pain during menstruation, she came to visit pediatric specialist outpatient service of our hospital. The patient's height increased slowly over the past year, 3-4 cm/ year. Current symptoms: Lower abdominal distending pain, low menstrual blood volume with a dark brown color and a small amount of blood clots,general appetite, dry stool, normal urination, and poor sleep at night. She was healthy before and denies a history of special diseases. Her father's height was 175 cm, her mother's height was 154 cm,and the genetic height was 158 cm. Physical examination: Her height was 156.2 cm, with a weight of 43 kg. Abdomen was soft without muscular tension and rebound tenderness. Tanner staging shows stage IV. Pubic hair (+), axillary hair (-) and leucorrhea (+). The tongue was red with a thin, white and greasy coating, and the pulse was slippery and rapid. Bone age showed that BA was 11.5 years old. B-ultrasound showed: The uterus volume was 13.02 mL, the right ovary volume was 5.54 mL, and the left ovary volume was 7.07 mL. TCM diagnosis:Dysmenorrhea of phlegm-dampness-stasis syndrome. Treatment method: Removing dampness and resolving phlegm, as well as resolving blood stasis and relieving pain. Prescription:Pericarpium Citri Reticulatae6 g,Poria9 g,Rhizoma Pinelliae6 g,Radix Glycyrrhizae3 g,Pollen Typhae9 g,Rhizoma Cyperi9 g andRadix Angelicae Sinensis9 g, with 7 sets. Each set was decocted to 200 mL and divided into 2 servings for being taken in the morning and evening respectively at a warm temperature.

Second visit on September 3, 2016: The second menstrual onset was on August 21, 2016,with a period of 2 days. There was no obvious abdominal pain during this menstrual onset. The amount was little with a pale color, and there was no blood clot. The color of leucorrhea was usually yellow, and her appetite was general. She was easy to fatigue, with poor sleep at night and normal stool and urination. Physical examination: Her height was 157 cm, with a weight of 44 kg. She had a pale red tongue, with a thin white coating, and a slippery and rapid pulse. Therefore, based on the former method,supplementing Qi was also applied. The previous prescription was addedRhizoma Dioscoreae12 g,Radix Astragali seu Hedysari9 g,Radix Codonopsis9 g,Cortex Eucommiae9 g,Semen Cuscutae12 g andLigusticum Chuanxiong Hort9 g, with 14 sets. Each set was decocted to 200 mL and divided into 2 servings for being taken in the morning and evening respectively at a warm temperature. She came to visit every 2 weeks thereafter.

Subsequent visit on November 26, 2016: The fourth menstrual onset was on November 17, 2016.Abdominal pain, normal menstrual blood volume,no blood clots, general appetite, easy fatigue,poor sleep at night, dry stool and yellow urine.Physical examination: A small amount of acne on the forehead and face, red tongue with a yellow coating,and a slippery and rapid pulse. Re-examination of B-ultrasound showed: The uterus volume was 24.35 mL, the right ovary volume was 2.80 mL, and the left ovary volume was 3.69 mL. Sex hormones: E2:98 pg/mL, PRL: 22.32 ng/mL, FSH: 4.91 mIU/mL, and LH: 7.61 mIU/mL. Following the previous method,the prescription was slightly modified. The specific medicines were as follows:Pericarpium Citri Reticulatae6 g,Poria9 g,Rhizoma Pinelliae6 g,Radix Glycyrrhizae3 g,Fructus Ligustri Lucidi15 g,Herba Ecliptae15 g,Rhizoma Anemarrhenae9 g,Cortex Phellodendri9 g,Rhizoma Cyperi9 g,Cortex Mori9 g,Radix Scutellariae6 g,Concha Ostreae15 g,Dens Draconis15 g,Radix Astragali seu Hedysari9 g andSclerotium Poriae Pararadicis9 g,with 14 sets. Each set was decocted to 200 mL and divided into 2 servings for being taken in the morning and evening respectively at a warm temperature.Metronidazole was also applied to the facial acne area.

The fifth visit on December 24, 2016: The fifth menstrual onset was on December 9, 2016, with a period of 7 days. No lower abdominal pain during the period, moderate menstrual blood volume, no blood clots, general appetite, a little fatigue, and sound sleep at night. Physical examination: Her height was 158 cm, with a weight of 48.4 kg. The facial acne had been healed. Her tongue was red, with a yellow coating, and she had a slippery and rapid pulse.Following the previous method, the prescription was slightly modified.Rhizoma Anemarrhenae,Cortex Phellodendri,Rhizoma Cyperi,Radix Scutellariae,Cortex Mori,Concha Ostreae,Dens DraconisandSclerotium Poriae Pararadiciswere removed, whileRhizoma Cimicifugae9 g, Cortex Eucommiae 10 g andSemen Cuscutae12 g were added. Each set was decocted to 200 mL and divided into 2 servings for being taken in the morning and evening respectively at a warm temperature. The prescription was applied for another month.

July 14, 2018: The patient stopped taking the prescription for more than 1 year and returned. Her menstruation was regular, with the last menstrual period (LMP) on July 2, 2018. The lower abdomen distending pain during menstruation recurred after taking cold drinks, and the menstrual blood volume was low, with a dark color. She was easy to fatigue,and susceptible to exogenous disease. Her urine and stool were normal, with good appetite and sleep.Physical examination: Her height was 164.8 cm,with a weight of 49.6 kg. She had a red tongue, with a yellow coating and a slippery and rapid pulse.Bone age: BA = 13 years old. B-ultrasound: The uterus volume was 35.65 mL, the right ovary volume was 4.16 mL, and left ovary volume was 5.59 mL.Sex hormone: E2: 460 pg/mL, PRL: 452.19 ng/mL,FSH: 1.55 mIU/mL, and LH: 1.66 mIU/mL. Following the previous method, the prescription was slightly modified. The specific medicines were as follows:Pericarpium Citri Reticulatae6 g,Poria9 g,Rhizoma Pinelliae6 g,Radix Glycyrrhizae3 g,Rhizoma Cyperi9 g,Pollen Typhae9 g,Radix Codonopsis9 g,Herba Agrimoniae10 g,Radix Salviae Miltiorrhizae9 g,Radix Paeoniae Rubra6 g,Concha Ostreae15 g andRadix Saposhnikoviae6 g, with 14 sets. Each set was decocted to 200 mL and divided into 2 servings for being taken in the morning and evening respectively at a warm temperature. Dysmenorrhea was stopped, with nothing special. Follow-up was kept.

August 14, 2020: The patient had had menstruation for 4 years and returned to visit. Her menstruation was regular, with the LMP on July 15, 2020 and a period of 6 days. Lower abdominal distending pain during menstruation, blood clots on the first day of menstruation, moderate amount, easy to fatigue, normal stool and urine, and sound sleep.Physical examination: Her height was 167 cm, with a weight of 50.4 kg. She had a dark red tongue,with a yellow greasy coating, and a slippery and rapid pulse. Bone age: BA = 14 years old. Following the previous method, the prescription was slightly modified. The specific medicines were as follows:Pericarpium Citri Reticulatae6 g,Poria9 g,Rhizoma Pinelliae6 g,Radix Glycyrrhizae3 g,Fructus Ligustri Lucidi15 g,Herba Ecliptae15 g,Rhizoma Cyperi69 g,Pollen Typhae9 g,Faeces Togopteri9 g,Concha Ostreae15 g,Caulis Sargentodoxae9 g,Semen Ziziphi Spinosae9 g, friedFructus Setariae Germinatus15 g,Radix Salviae Miltiorrhizae9 g,Semen Persicae9 g andFlos Carthami6 g, with 21 sets. Each set was decocted to 200 mL and divided into 2 servings for being taken in the morning and evening respectively at a warm temperature.

The patient had regular menstruation for more than 4 years since menarche, and lower abdominal distending pain during menstruation mostly appeared after drinking cold drinks. It was obvious during the 3-5 days. The height increased by 10 cm, which had exceeded the 158 cm genetic height, reaching the expectation of her family members.

ANALYSIS ON THE TREATMENT

Internal Accumulation of Phlegm-damp ness as the Main Pathogenesis

In this case, the patient's main symptom was lower abdominal distending pain after menstrual onsets. Her family members wanted to treat dysmenorrhea after menstrual onsets and to help her height grow by TCM during this period. Her bone age at menarche was in line with her actual age,so her disease was dysmenorrhea. Climate in the southeast coastal area in China is usually humid.Under the influence of this unique regional climate environment, constitutive characteristics and TCM syndromes also have their own features.

Phlegm belongs to water, and movement of phlegm indicates dampness, which are governed by the spleen. Formation of phlegm and dampness is responsible for spleen deficiency, failing to transport and transform. Body fluid metabolism is abnormal, which accumulates and turns into phlegm and dampness. The spleen is middle-earth, prefers dryness, and is often disturbed by dampness. The spleen in children is often deficient and prone to produce phlegm and dampness, which accumulate in the body and block Qi movement[7,8]. If phlegm stagnates in the breasts, masses in them can be found. If dampness accumulates in the spleen and stomach, there will be poor appetite and eating less. The spleen dominates muscle. Dampness stagnating in the skin leads to loose skin and muscle, so the person is fat, fatigued and sleepy.Pubescent children with menstrual onsets suffer from uneven kidney Qi, disharmony of Thoroughfare and Conception Channels, as well as unsmooth liver Qi. Phlegm and dampness accumulate internally in the body, fight with blood, flow into the Thoroughfare and Conception Channels, and accumulate in the uterus. Qi and blood in the Thoroughfare and Conception Channels change dramatically before and after menstruation. When having too much cold food at this period, it causes poor circulation of Qi and blood in the Thoroughfare and Conception Channels and obstruction of menstrual blood circulation in the uterus, resulting in "pain caused by blockage".

Simultaneous Use of Removing Dampness and Resolving phlegm Combined with Nourishing Yin and Reducing Fire

In the treatment of chronic diseases in children,Professor ZHAO Jun is good at throwing a stone to clear the road. That is to say, She firstly gives a small amount of medicines to test the patient's drug tolerance. In this case, the patient's syndrome was internal accumulation of phlegm-dampness,combined with irregular menstruation and slow growth in height. Therefore, the main treatment method was invigorating spleen to resolve phlegm,supplemented by regulating Thoroughfare and Conception Channels and nourishing kidney-Yin.Erchen Decoction (二陳湯) and Erzhi Pills (二至丸)were usually prescribed.

Erchen Decoction is recorded inPrescriptions of the Bureau of Taiping People's Welfare Pharmacy(《太平惠民和劑局方》), "It treats diseases caused by phlegm and fluid retention, or vomiting and nausea, or dizziness and palpitations, or discomfort in the gastric cavity, or cold and fever, or disharmony caused by improper food." The prescription plays the role of promoting Qi and strengthening spleen,as well as removing dampness and resolving phlegm. In the prescription,Rhizoma Pinelliaeis the sovereign for drying dampness and resolving phlegm.Pericarpium Citri Reticulataeis the minister for regulating Qi and activating stagnation, as well as drying dampness and resolving phlegm.Poriainvigorates spleen and diffuses dampness to help resolve phlegm, combined withRhizoma Pinelliae,achieving the effect of dampness and phlegm elimination[9]. Professor ZHAO Jun believes that the spleen and stomach are the pivot for Qi movement ascending and descending. Erchen Dcoction enters the pivot to dry dampness and resolve phlegm, so as to help spleen transportation.

In Erzhi Pills, doses ofFructus Ligustri LucidiandHerba Ecliptaeare small but they have specific functions. They can supplement liver and kidney,nourish Yin and regulate menstruation. Professor ZHAO Jun believes that the spleen and kidney play a pivotal role in pubescent children's development.Strengthening spleen, dispelling dampness and resolving phlegm are supplemented by the method of regulating Thoroughfare and Conception Channels as well as nourishing Yin and reducing fire. The Thoroughfare channel is the sea of blood,while the Conception Channel governs the fetus,storing blood, conveyance and dispersion, as well as the sea of blood. The Thoroughfare and Conception Channels are closely related to each other physiologically, which also indicates the pathological mutual influence.Jing-yue's Complete Works(《景岳全書》) records, "Abdominal pain during menstruation may be deficient or excessive."Rhizoma CyperiandPollen Typhaeare often used to regulate Qi and relieve pain. However,TCM treatment must adhere to basic principles in syndrome differentiation and treatment, and distinguish deficiency and excess, cold and heat, as well as Qi and blood of diseases in order to achieve better results.

Pay Attention to the Spleen and Kidney(Regulating Spleen and Kidney Method)

W h e n P r o f e s s o r Z H A O J u n t r e a t s development-related diseases in pubescent children,she firstly focuses on the spleen and kidney. It is believed that the spleen and kidney are closely related, coordinating and interacting with each other. Her clinical medication is closely related to the pathogenesis, so as to regulate the child's body of tender Yin and tender Yang (陽), and exert the function of regulating spleen and kidney.Overview on Syndromes and Treatment of Five-Zang(五臟)of Secrets of Nursing a Baby(《育嬰家秘?五臟證治總論》) records that a newborn is like a bud of grass or a tree. When it is spring, its Qi is sufficient, also namely Qi of Shaoyang (少陽), so the bud can grow without stopping. The newborn is fed with milk rather than food and drink, and the spleen is not used, so its Qi is still weak, and it is called deficiency. Those with deficient spleen Qi also have deficient grain Qi.The kidney belongs to water, and stores Yin essence of a person. The kidney is easy to become deficient.When natural endowment is insufficient after a baby is born, muscles and bones grow slowly. Then the baby will be short and thin. That is to say, insufficient natural endowment indicates deficient kidney essence and kidney Qi, which leads to slow growth and development of bones. Therefore, it will be short stature. The spleen belongs to earth and it is the mother of all things. If improper diet hurts the spleen and stomach, they will fail to promote Qi movement ascending and descending, and the spleen will fail to transport. Then, Qi and blood cannot be produced, and five Zang lack sources to nourish the skin, flesh, muscles and bones. Finally, growth and development will be slow. At the same time, the kidney essence and kidney Qi cannot be nourished by acquired essence of food and drinks, which also affects the growth governed by the kidney. People with insufficient sleep or insomnia during puberty,their height growth will also be affected. Therefore, it is necessary to add tranquilizers in Chinese materia medica to the prescription to help height growth.

SUMMARY

During the treatment for this case, there was no relevant TCM treatment plan or case report for reference. The main feature of the treatment for this case is adhering to the TCM thinking of syndrome differentiation. From the perspective of modern medicine, children's height growth is affected by multiple factors such as genetics, environment,nutrition, etc[10]. But due to increased secretion of estrogen in children during puberty, closure and ossification of epiphyses accelerates[11], which ultimately affects children's final height. Professor ZHAO Jun took individual genetic characteristics and parents' expectations into consideration when intervening in the pubescent child's height. She combined clinical practice with multiple factors,comprehensive analysis of data gained by four diagnostic methods, and detailed medical history.She examined the pathogenesis and stuck to the prescription. After long-term cooperation with her family members, satisfying efficacy was achieved.