Two children may arrive in clinic with the same diagnosis of asthma and tell very different clinical stories. One may have had eczema since infancy, allergic rhinitis, environmental allergies, allergen-triggered wheezing and very little sputum. Another may have developed wheezing after repeated respiratory infections and now presents with a lingering wet cough and abundant Phlegm. Both have asthma. In Chinese medicine, however, they may require very different treatment.
This distinction is central to Giovanni Maciocia’s pediatric asthma teaching. Maciocia argued that the traditional categories of Xiao (wheezing) and Chuan (breathlessness) did not adequately explain the atopic children he encountered, particularly the relationship between allergic asthma and atopic eczema.¹ He distinguished allergic asthma—associated with eczema, allergic rhinitis, familial incidence, environmental allergy, Wind in the bronchi and deficiency of the Lung- and Kidney-Wei systems—from non-allergic asthma, in which Phlegm and deficiency of the Lung, Spleen and Kidney assume greater importance.
What I find particularly valuable is not only the model itself, but how Maciocia arrived at it. Clinical observation did not fit neatly into the inherited theory, so he reconsidered the theory. That remains relevant today. Contemporary Western medicine also recognizes childhood asthma as heterogeneous, with different phenotypes and endotypes rather than one uniform disease process.² Contemporary Chinese medicine continues to develop differentiated approaches to pediatric asthma, including formal guidance on pattern differentiation and treatment.³˒⁶
The Developing Lung
Before discussing asthma itself, it is worth remembering that pediatric respiratory disease occurs in a developing child. Maciocia describes the pediatric Zang Fu as relatively immature and vulnerable, particularly the Lung and Spleen, with the Lung especially susceptible to external pathogenic factors.¹˒⁴ At the same time, he describes children as “clear” and “with vitality”: illness may develop quickly, but change and recovery can also be rapid.¹
Western developmental physiology offers an interesting parallel. The human Lung is not structurally mature at birth; alveolar formation continues through childhood and into adolescence, while the airways and respiratory mechanics also continue to mature.⁵ This should not be read as a biomedical explanation of pediatric Lung immaturity in Chinese medicine. It does, however, reinforce an important clinical point: respiratory disease in a child occurs within a system that is still maturing.
I see this developmental quality frequently in practice. A wet cough becomes dry; wheezing resolves while rhinitis persists; respiratory symptoms settle while eczema becomes more prominent. This rapid movement is one of the reasons pediatric treatment can be so rewarding, but it also means that the pattern needs to be reassessed rather than assumed to remain static. What was clinically dominant two weeks ago may no longer be what requires treatment today.
Rethinking Xiao-Chuan
Maciocia states the problem directly: “I find that the theory of Xiao and Chuan do not explain the pathology of atopy and the association between allergic asthma and atopic eczema.”¹ This is more than a terminology issue. Maciocia was questioning whether the traditional disease category adequately described the pathology he was seeing in modern children.
For allergic asthma, he describes childhood onset, familial tendency, environmental allergy, eczema and allergic rhinitis, Wind in the bronchi and deficiency of the Lung- and Kidney-Wei systems. His summary model specifies “No Phlegm,” while his fuller clinical description is slightly more nuanced, describing “little or no expectoration of phlegm.” His non-allergic asthma picture is different: later onset, Phlegm in the bronchi and deficiency involving the Lung, Spleen and Kidney.¹
This distinction prevents us from automatically equating asthma with Phlegm. One child may wheeze dramatically yet have almost nothing to expectorate, with eczema, perennial rhinitis and clear environmental triggers. Another may have developed asthma following repeated respiratory infections and now present with a persistent wet, Phlegmy cough. The biomedical diagnosis may be the same; the Chinese medicine pattern is not.
Modern asthma phenotyping comes from a very different scientific framework, but the clinical parallel is useful. Contemporary pediatric asthma is likewise understood as a heterogeneous condition involving different phenotypes and underlying mechanisms.² The systems are not describing the same physiology, but they arrive at a useful common principle: the diagnostic label alone does not tell us everything we need to know about the child.
Asthma in the Atopic Child
The part of Maciocia’s model that resonates particularly strongly with my practice is his attention to atopy. In children I treat for asthma, it is striking how often another atopic condition is present: eczema, allergic rhinitis, environmental allergies, food allergy, or several together. This is an observation from my own clinical population, but it has changed the way I take a pediatric respiratory history.
I rarely ask only about the breathing. I want to know what happened to the skin and nose, what the known triggers are, and perhaps most importantly, what came first. Was there eczema in infancy? Did rhinitis precede the asthma? Is wheezing viral, exercise-induced, seasonal or allergen-triggered? Does congestion persist even when the breathing is good? Were there repeated respiratory infections before the wheezing began? Is the child completely well between episodes, or is there always some residual cough, congestion or skin involvement? The chronology can tell us more than the diagnostic label.
This is where Maciocia’s discussion of allergic asthma becomes particularly useful. Asthma is no longer viewed as an isolated Lung complaint; the skin, nose, respiratory tract and constitutional susceptibility become part of the same clinical history. This also sits comfortably alongside modern recognition that eczema, allergic rhinitis, asthma and food allergy frequently coexist, although their relationships are more complex than a simple, inevitable progression from one atopic disease to the next.
Why the Lung Appears in a Discussion of Eczema
Maciocia’s pediatric framework does not view eczema solely as a disorder of the skin. Hereditary factors and dysfunction involving the Lung and Spleen may overlap with Heat, Dampness, Phlegm, Qi and Blood deficiency and other contributing factors.⁴ 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, while impaired Lung function may disturb their normal dispersal and movement.
Traditionally, this relationship is summarized by describing the Spleen as the source of Phlegm and the Lung as its container, but pediatric presentations are rarely explained by that relationship alone. The presence of Dampness does not make every case of eczema a Spleen disorder, just as respiratory involvement does not make the pathology exclusively one of the Lung. Nor should fluid in an eczematous lesion be interpreted literally as Phlegm. The relevance of these functional relationships still has to be demonstrated in the individual child.
Maciocia’s explanation of atopic eczema is more specific. He describes Wind and Damp-Heat retained in the skin against an underlying deficiency of the Lung- and Kidney-Wei systems.¹ The pathology visible at the surface may therefore differ from the susceptibility underlying it. A child can also move between apparently different manifestations: the breathing may improve while the eczema remains active, or the skin may settle while allergic rhinitis becomes more prominent. The manifestation changes, but the broader constitutional picture may still require attention.
Western allergy has undergone its own evolution. The traditional atopic march described a progression from eczema and food allergy toward allergic rhinitis and asthma. Contemporary research demonstrates that this progression is not universal; children may follow several different trajectories, increasingly discussed in terms of atopic multimorbidity rather than one inevitable march.⁷
Hence, the two medical languages should not be collapsed into one another. Skin-barrier dysfunction is not Wei-Qi deficiency, allergic sensitization is not Wind, and biomedical mucus is not synonymous with Chinese medical Phlegm. Both perspectives nevertheless encourage us to look beyond an isolated organ diagnosis and ask why several apparently different manifestations may be occurring in the same child.
Classical Formulas, Pediatric Modifications
The Little Treasures formulas become particularly interesting when we examine how classical prescriptions were adapted to pediatric presentations. Their classical antecedents provide the therapeutic architecture, while the resulting formulas address particular pediatric patterns and the changing clinical picture of the child.
Breathe Easy, for example, takes Su Zi Jiang Qi Tang as its classical antecedent. The classical formula is built around failure of Lung-Qi to descend with Phlegm obstruction and deficiency below. In the Little Treasures version, Maciocia shifts the emphasis toward restoring Lung-Qi descent, expelling Wind from the bronchi and supporting Kidney-Yang and the Kidney Defensive-Qi aspect.⁴ This is also where Maciocia’s allergic/non-allergic distinction remains important. We should not assume that every child with asthma has Phlegm or Spleen deficiency simply because these are common concepts in traditional asthma strategies. His allergic-asthma model emphasizes little or no expectoration of Phlegm, with his summary chart simply stating No Phlegm.
For residual Phlegm-Heat following an invasion of Wind, Resolve Phlegm takes Wen Dan Tang in a more specifically pulmonary direction, clearing Lung-Heat, resolving Phlegm and restoring Lung-Qi descent. Maciocia specifically describes the Little Treasures adaptation as having a stronger action in resolving Phlegm than its classical antecedent.¹ This is a different clinical situation from the allergic child with wheezing but little or no Phlegm. Within Maciocia’s framework, residual Phlegm-Heat may remain following the acute phase of a respiratory infection.
Chest Release, based on Qing Qi Hua Tan Tang, represents the more acute Phlegm-Heat strategy. Maciocia describes the modification as having a stronger Phlegm-resolving action compared with the classical antecedent.¹ Maciocia also distinguishes Chest Release from Resolve Phlegm clinically. Chest Release addresses the acute productive Phlegm-Heat presentation, whereas Resolve Phlegm becomes relevant when Phlegm-Heat remains after the acute illness.
When eczema becomes dominant, the formula strategy changes again. Clear Radiance, with Chu Shi Wei Ling Tang as its classical antecedent, addresses Damp-Heat and Wind in the skin. Maciocia describes its primary action as resolving Dampness, clearing Heat and expelling Wind from the skin, while explicitly identifying strengthening the Wei systems of the Lung and Kidney as a difference from the classical antecedent.¹ This modification is particularly interesting within his atopic model because it allows the formula to address the skin manifestation predominantly while retaining attention to the underlying susceptibility.
When constitutional deficiency and recurrent susceptibility become the concern, Little Sentinel takes the Qi-and-Blood-tonifying architecture of Ba Zhen Tang toward a pediatric pattern of Lung-, Spleen- and Kidney-Qi deficiency. Maciocia explicitly identifies tonifying the Kidneys as a difference from its classical antecedent.¹ He describes Little Sentinel as a general tonic for children with deficiency of the Lung, Spleen and Kidneys, with an emphasis on constitutional deficiency and susceptibility.¹
In my own practice, the way the presentation changes over time is often as informative as the complaint that first brought the child in. Wheezing may settle while a residual Phlegmy cough persists; respiratory symptoms may improve while eczema or rhinitis becomes more prominent; later, recurrent infections or constitutional weakness may become the greater concern. The approach follows what is clinically dominant, while keeping the broader pattern and underlying susceptibility in view. The Little Treasures formulas are useful here not only in relation to their associated patterns, but for what their modifications reveal about adapting classical formula architecture to a pediatric presentation that may change over time.
I use these formulas frequently, but they are part of a larger clinical toolbox. Acupuncture follows the same differentiation, while environmental exposures, lifestyle and the child’s conventional medical management remain part of the clinical picture.
Treating the Child, Not Just the Diagnosis
The movement between these formulas points to a larger principle in pediatric practice: Biao and Ben, commonly translated as Branch and Root. Clinically, I think of the distinction more simply: what needs attention now, and what is making this child susceptible underneath it? Maciocia’s treatment schemes make this explicit, separating treatment of Biao and Ben and, where appropriate, combining formulas directed toward the current manifestation with those addressing constitutional deficiency. In his allergic-asthma material, for example, Little Sentinel may be combined with Breathe Easy to address Ben and Biao together.¹ The point is not that one is always treated before the other, but that the clinical priority may change as the child’s presentation changes.
That distinction is useful because it brings us back from the formula—or the diagnosis—to the child in front of us. What does the cough actually sound like? Is there Phlegm? What is happening with the skin and nose? What came first? What persists between exacerbations? What triggers the symptoms? What has changed since the last visit? And what appears to be maintaining this child’s susceptibility? The answers may lead us somewhere quite different from where the diagnostic label alone would suggest.
Western medicine contributes another essential layer of information. Asthma severity and control, allergic sensitization, medication use, eczema, rhinitis and specialist findings all help define the clinical context, even though they do not determine the Chinese medicine pattern. Equally, Chinese medicine should not replace appropriate biomedical assessment and treatment of pediatric asthma. Asthma can become serious rapidly in children, and conventional diagnosis, monitoring and rescue or controller medication remain essential when indicated. Working with both perspectives does not require translating one into the language of the other. Skin-barrier dysfunction does not have to become Wei-Qi deficiency, nor allergic sensitization Wind, for either to contribute something useful to our understanding of the child.
In many ways, Maciocia’s own approach to pediatric asthma offers the best example of this willingness to look again. When Xiao-Chuan did not adequately explain the atopic children he was seeing, he did not simply force those children back into the existing model. He reconsidered the pathology. Continuing that work today need not mean preserving every proposition unchanged. It means retaining the same willingness to observe carefully, differentiate what is actually present and reconsider our models when the clinical picture—or the knowledge surrounding it—asks us to.
The Little Treasures formulas are valuable clinical tools, but their greater value may lie in the reasoning they embody. A child who arrives with asthma brings more than an asthma diagnosis into the treatment room. The breathing, skin, nose, allergic history, recurrent infections, constitution and the way these manifestations change over time may all be relevant to understanding what requires treatment now and what may be contributing to susceptibility underneath it. The formula still has to fit the pattern, and the pattern still has to fit the child.
Acupuncture follows the same differentiation, while environmental exposures, lifestyle and the child’s conventional medical management remain part of the clinical picture.
Footnotes
- Maciocia G. Children’s Complaints. Giovanni-Maciocia.com. Pediatric course and teaching material.
- Roberto G, Barberi S, Marseglia GL, Licari A. What’s new in pediatric asthma and rhinitis phenotypes and endotypes? Current Opinion in Allergy and Clinical Immunology. 2024;24(2):73–78.
- Zhao X, Cai Y, Yan H, Dong Y. Review of research on traditional Chinese medicine for the prevention and treatment of pediatric asthma. Journal of Nanjing University of Traditional Chinese Medicine. 2026;42(1):9–18.
- Tjeertes P. The Little Treasures—Paediatric Formulas Explained. Lecture 8. In: Chinese Herbal Formulas in Practice: Foundations, Formulations & Clinical Integration. 2025. Course material.
- Trachsel D, Erb TO, Hammer J, von Ungern-Sternberg BS. Developmental respiratory physiology. Paediatric Anaesthesia. 2022;32:108–117.
- Zhao X, Qing YH, Wang YP, et al. The Guideline for the Diagnosis and Treatment of Pediatric Asthma in Chinese Medicine (Revised). Journal of Nanjing University of Traditional Chinese Medicine. 2022;38(6):476–482.
- Mrkić Kobal I, Plavec D, Vlašić Lončarić Ž, Jerković I, Turkalj M. Atopic march or atopic multimorbidity—overview of current research. Medicina (Kaunas). 2024;60(1):21.
About the Author
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: