The Developing Spleen and the Modern Child

The pediatric Spleen described in Chinese medicine developed in a very different food environment from the one many children inhabit today. In clinic, I increasingly see children whose diets are restricted not simply by appetite or digestion, but by sensory preferences, feeding difficulties, food allergy, eczema-related elimination, fear of adverse reactions or a long history of eating only a narrow range of accepted foods. By the time they reach us, the reason the diet became restricted and the physiological consequences of living on that diet may no longer be the same thing.

One child may eat only a handful of foods, refuse mixed textures, yet have a perfectly good appetite for preferred foods. Another may once have eaten broadly but, after recurrent illness, now eats small amounts, tires at meals, complains of abdominal discomfort and has gradually lost interest in food. Both may arrive described as “picky eaters,” and both may have similarly restricted diets by the time we see them. Clinically, however, they have arrived there by very different routes. In the first child, feeding behavior may have shaped the diet before digestive consequences developed; in the second, digestive or constitutional weakness may have helped shape the feeding behavior itself.

The importance of digestion in childhood long predates Maciocia. Chinese medicine has a long pediatric tradition, with physicians such as Qian Yi (1037–1119) among its influential early practitioners.⁶ Maciocia works within this tradition, describing the Spleen and digestive system as relatively weak in newborns and remaining so for at least the first three to four years. Within his pediatric framework, this vulnerability is associated particularly with Food Retention or Accumulation, Qi stagnation and Cold in the Spleen and Intestines.¹

That vulnerability, however, is a physiological starting point rather than a ready-made diagnosis. The pediatric digestive picture is not limited to Spleen deficiency. Accumulation, Qi stagnation, Dampness, Phlegm, residual pathogenic factors and deficiency may appear alone or in combination, and the same complaint may lead us in very different directions depending on the pathology underneath it.

When the Problem Is the Eating, Not the Appetite

I see children who accept only crunchy or dry foods, reject sauces or mixed foods, gag at particular textures, dislike strong smells or become distressed when unfamiliar foods appear on the plate. Sweet or salty preferences may also be striking. These details belong in the history, but their meaning depends on the rest of the child. A child can be genuinely hungry and digest accepted foods comfortably while still being unable to tolerate much of what is offered.

Contemporary pediatrics provides useful language for some of these presentations. Pediatric feeding disorder is defined as impaired oral intake that is not age-appropriate and associated with dysfunction in one or more of four domains: medical, nutritional, feeding skill and psychosocial.⁷

That framework does not determine a Chinese medicine diagnosis, but it can help clarify what part of the presentation we are actually looking at. The situation becomes more interesting when the feeding problem begins to shape the diet itself. A child may initially avoid foods because of texture, smell or presentation and eventually live on a small number of preferred foods. At that point, I need to distinguish the reason the repertoire became narrow from the physiological consequences of eating within that repertoire. A sensory feeding difficulty does not become Food Accumulation simply because the resulting diet is limited. But the same child can also develop constipation, irregular appetite, abdominal discomfort or another digestive pattern that deserves treatment in its own right.

The feeding difficulty and the digestive pattern may therefore require different interventions even when they coexist in the same child. Identifying a feeding disorder does not make Chinese medicine irrelevant to the case, just as identifying Food Accumulation does not explain the feeding disorder. They may be two different clinical problems occurring in the same child.

Growth and nutritional status add another layer. A narrow repertoire in a child who is growing appropriately and meeting nutritional needs raises different questions from progressive restriction accompanied by faltering growth, nutritional deficiency or significant distress.⁷

Progressive loss of accepted foods, growth or nutritional concerns, swallowing difficulties, significant mealtime distress or suspected food allergy should also lower the threshold for appropriate pediatric, feeding, dietetic or allergy assessment.

Sensory restriction, however, is only one way foods disappear from a child’s diet.

Food Allergy Changes the Diet, Too

One child may be avoiding milk because of confirmed IgE-mediated allergy. Another may have removed dairy because it is suspected of aggravating eczema. A third may reject it because of texture or smell. By the time these children arrive in clinic, their diets may look surprisingly similar even though the reasons for restriction are completely different.

IgE-mediated food allergy, sensitisation without clinical reactivity, food intolerance, sensory food avoidance and Chinese medical Food Accumulation are distinct concepts. Current allergy guidelines emphasize an allergy-focused clinical history together with appropriate testing and, when necessary, oral food challenge in establishing IgE-mediated food allergy.⁸

I would not present a Little Treasures formula as treatment for IgE-mediated food allergy. What Chinese medicine can still do is differentiate the child who has the allergy. That child may also have constipation, loose stools, Food Accumulation, eczema, Dampness, Phlegm or respiratory symptoms. Those findings may provide legitimate treatment targets without implying that the underlying allergy has been removed.

Families dealing with eczema also sometimes arrive having already removed several foods from the diet, whether because of suspected triggers, previous testing or advice they have received. This history deserves careful attention. Evidence does not support indiscriminate food elimination as a general treatment for atopic dermatitis: a systematic review and meta-analysis found only slight, potentially unimportant improvement in eczema severity, while emphasizing that any potential benefit needs to be balanced against the risks of elimination.³ This does not mean that diet is irrelevant to eczema management. Dietary advice may form part of an individualized treatment plan, including within Chinese medicine, but removing foods from an already restricted child’s diet should have a clear rationale. The history consequently needs to include not only what the child no longer eats, but why each food disappeared.

A medically necessary exclusion, an empiric elimination for eczema and a sensory refusal may produce the same empty space on the plate while carrying very different implications for diagnosis, nutrition and treatment. “Poor appetite” is therefore not enough to explain what we are seeing. The child may be avoiding food, filling up between meals, recovering from illness or genuinely showing a digestive pathology. The clinical question is what is actually maintaining the presentation now.

Classical Formulas, Pediatric Modifications

Grazing through the day, rarely hungry at meals, distended after eating, with irregular stools and a tongue coat that supports the digestive picture. If the rest of the presentation points toward Food Accumulation and Qi stagnation, Tummy Soothe illustrates one possible formula strategy.

Its classical antecedent is Bao He Wan. Maciocia gives Tummy Soothe the actions of moving Qi and dissolving Food Accumulation, with patterns including Retention of Food, Qi stagnation in the Intestines and Liver-Qi stagnation. Most revealingly, when comparing it with its classical antecedent, he identifies its greater “Moving Qi action” as a difference.¹˒² That short phrase tells us quite a lot. Bao He Wan provides the classical architecture of Food Retention, while the pediatric adaptation gives greater therapeutic weight to movement of Qi. Accumulation remains important, but so does stagnation.

Now change the history slightly. The child has recently had an upper respiratory infection, remains somewhat listless and nasal, and has begun picking at food. The words “poor appetite” have not changed very much. The pathology has.

Sino Relief, based on Qing Yan Tang and Li Yan Cha, addresses residual Damp-Heat in the head and Damp-Heat in the Stomach channel.¹˒² Within Maciocia’s discussion of this pattern, he describes a child who remains somewhat listless and nasal after an upper respiratory infection, with Dampness affecting the appetite so that the child “lacks appetite and picks at the food.”¹ Here appetite belongs to a residual post-infectious picture rather than Food Accumulation.

Compared with its classical antecedents, Sino Relief has a stronger action in resolving Dampness and an emphasis on resolving Toxic Heat. Maciocia also cautions that its cooling effect may injure the Spleen if it is used for too long.¹ The Little Treasures course similarly identifies the residual Damp-Heat pattern and its Heat-clearing, Dampness-resolving emphasis.² That caution is almost as useful as the indication. The appetite may remain imperfect even after the pathology that originally justified the formula has changed. Persistence of the symptom does not necessarily mean persistence of the underlying pattern

The comparison between these two formulas is more useful to me than assigning “poor appetite” to the Spleen by default. One child may have Food Accumulation with stagnation; another may pick at food because Dampness remains after an illness. The complaint is similar, but the therapeutic logic is not. The post-infectious child also takes us beyond the digestive system. Once congestion, cough or Phlegm becomes prominent, the question is no longer simply what the Spleen is doing.

When the Spleen Meets the Lung

Within Chinese medical physiology, the Spleen transforms and transports fluids while the Lung disperses and descends them and regulates the waterways. Impaired Spleen transformation may therefore contribute to Dampness and, where the pattern supports it, Phlegm.⁴ The relationship is clinically useful precisely because it is not automatic. A child with dry, allergen-triggered wheezing and essentially normal digestion presents a different problem from one with a wet, rattling cough, poor appetite, abdominal distension and a thick or greasy tongue coat.

When Phlegm becomes the dominant respiratory pathology, the formula strategy changes again. Resolve Phlegm, based on Wen Dan Tang, reflects a residual Phlegm-Heat strategy, while Chest Release, based on Qing Qi Hua Tan Tang, represents the more acute Phlegm-Heat strategy.¹˒² Both formulas were discussed more fully in Article 1; what matters here is the Spleen-Lung relationship they illustrate. Impaired Spleen transformation may generate Dampness and contribute to the formation of Phlegm, while the Lung becomes an important site of its respiratory manifestation.

The same restraint applies when eczema and dietary concerns coexist. Clear Radiance is formulated around Maciocia’s Damp-Heat and Wind skin pattern.¹˒² Eczema may coexist with food allergy or dietary restriction, but that coexistence does not by itself establish what is driving the skin presentation.

Nor does every child remain in an excess or residual pathogenic picture. Little Sentinel, based on Ba Zhen Tang, moves the discussion toward constitutional deficiency of the Lung, Spleen and Kidneys; Maciocia specifically identifies tonifying the Kidneys as a difference from its classical antecedent.¹˒²

These formulas are not stages through which a child is expected to progress. They represent different therapeutic directions arising from different pathology, while Maciocia’s modifications show how the emphasis of a classical formula may be adjusted for the pediatric presentation.

The relationship between digestion, immunity and respiratory disease also raises a more contemporary question. Modern research increasingly examines the gut microbiome and intestinal barrier in relation to allergic disease and childhood asthma. How much of that research is useful to us as Chinese medicine practitioners, and where do the parallels stop?

The Microbiome: A New Language for an Old Clinical Relationship?

Research increasingly examines relationships among diet, gut microbial ecology, microbial metabolites, epithelial barrier function, immune development and allergic disease.⁵˒⁹ Systematic reviews of pediatric asthma have likewise reported associations involving gut and airway microbiome characteristics.⁵ Spleen-Qi deficiency is not dysbiosis. Food Accumulation is not a microbiome profile. Dampness is not increased intestinal permeability. And while “leaky gut” is often used as shorthand for increased intestinal permeability, the term can become too imprecise to be clinically useful when intestinal barrier function is what is actually being discussed. Once those equivalences are set aside, the research becomes more interesting.

Diet can influence microbial ecology; microbial metabolites interact with immune development; epithelial barrier function is relevant to allergic disease; and relationships between microbial communities and respiratory health continue to be investigated.⁵˒⁹ These findings give us additional ways to think about the biological context in which diet, immunity and allergic or respiratory disease develop, but their clinical interpretation is considerably more complicated than the popular idea that a child’s symptoms can simply be traced back to “the gut.”

Chinese medicine arrived at its relationships among digestion, fluids, the Lung and constitutional susceptibility through a very different medical framework. Contemporary research does not validate those relationships in biomedical terms, nor does it need to in order to be clinically informative. The danger is that “the microbiome” or “the gut” simply becomes a modern version of “the weak Spleen”—an explanation broad enough to account for almost anything and therefore too broad to help us differentiate.

That distinction matters when we return to the child in front of us. A restricted diet, poor appetite or narrow food repertoire may look superficially similar in the history, but the reason it developed—and what it means clinically—may be entirely different.

Treating the Child, Not the Diet

By the time I have taken a full history, “picky eating” or “poor appetite” often looks quite different from the complaint that first arrived in the treatment room. A child with Food Accumulation, Qi stagnation or deficiency may eat poorly, but so may a child who is hungry, digests comfortably and has a severely restricted sensory repertoire. The diet may look similar on paper; what matters clinically is how the child arrived there and what is maintaining the presentation now.

That is why I still come back to fairly ordinary questions. What does this child actually eat? When are they hungry? Do they sit down for meals or graze throughout the day? Which foods are reliably accepted, and is that range expanding or narrowing? Why have foods disappeared? What happens after eating? How is the child growing? Those answers then have to be put back into the whole presentation: stools, skin, nose, lungs, sleep, energy, recurrent illness, tongue and the rest of the Chinese medicine examination. Food may be central to the history without the gut necessarily being the explanation for the case.

Maciocia worked from a classical pediatric physiology in which the developing Spleen deserved particular attention, but his formulas repeatedly show the need to refine that starting point according to the pathology actually present. Contemporary practice asks us to extend the same discipline. Feeding-disorder frameworks, food-allergy diagnostics, nutritional assessment and microbiome research give us information he did not have in the same form. Rather than retrofitting each modern finding into a familiar Chinese medicine category, we can use that information to sharpen the questions we ask and the distinctions we make.

The developing Spleen therefore remains important, but it is the beginning of the clinical question rather than its answer. A restricted diet may be the consequence of digestive pathology, the cause of later digestive consequences, or part of a feeding or allergic problem that began elsewhere. Sometimes more than one of these processes is present in the same child.

The diet tells us what the child is eating. Differentiation asks why—and what has developed as a result.

Footnotes
  1. Maciocia G. Children’s Complaints. Giovanni Maciocia; pediatric course and teaching material.
  2. Tjeertes P. The Little Treasures—Paediatric Formulas Explained. Lecture 8. In: Chinese Herbal Formulas in Practice: Foundations, Formulations & Clinical Integration. 2025. Course material.
  3. Oykhman P, Dookie J, Al-Rammahy H, et al. Dietary elimination for the treatment of atopic dermatitis: a systematic review and meta-analysis. Journal of Allergy and Clinical Immunology: In Practice. 2022;10(10):2657–2666.e8.
  4. Maciocia G. The Foundations of Chinese Medicine: A Comprehensive Text. 3rd ed. Elsevier; 2015.
  5. Aldriwesh MG, Al-Mutairi AM, Alharbi AS, et al. Paediatric asthma and the microbiome: a systematic review. Microorganisms. 2023;11(4):939.
  6. Li M, Liang Y. Qian Yi, super pediatrician. Journal of Traditional Chinese Medical Sciences. 2016;3(3):195–202.
  7. Goday PS, Huh SY, Silverman A, et al. Pediatric feeding disorder: consensus definition and conceptual framework. Journal of Pediatric Gastroenterology and Nutrition. 2019;68(1):124–129.
  8. Santos AF, Riggioni C, Agache I, et al. EAACI guidelines on the diagnosis of IgE-mediated food allergy. Allergy. 2023;78(12):3057–3076.
  9. Iweala OI, Nagler CR. The microbiome and food allergy. Annual Review of Immunology. 2019;37:377–403.
About the AuthorKristina-Elminoufi.

Kristina Elminoufi, Ph.D., LAc.| Associate Practitioner at Yo San University

Kristina Elminoufi, L.Ac., Ph.D., is a California board-certified acupuncturist and herbalist with a Master’s degree in Traditional Chinese Medicine and an interdisciplinary Ph.D. spanning psychology, sociology, and journalism. She has a particular focus on pediatrics and takes a whole-child approach to care, alongside clinical interests in women’s health and fertility, mental-emotional health, chronic pain, and internal medicine. Her approach integrates Chinese medicine with Western medical perspectives and emphasizes individualized care and collaboration with other healthcare practitioners. Kristina practices at Yo San University’s Community Clinic in Venice and Trinity Acupuncture in Torrance, California, and is the founder of Little Qi, a pediatric health and wellness initiative rooted in Traditional Chinese Medicine.

To learn more about Kristina’s work, visit https://www.wayofthetao.com.

Further Study

Explore more of Giovanni Maciocia’s teaching on Pediatrics in Chinese medicine: