October 1999 - Partial Translation from: "Curare i bambini con il Tuina", Medicina Naturale n.5, 2000,

A Clinical Experience in Treating Children with Tuina:
Four Weeks at the Paediatric Department of Jiangsu Provincial Hospital in Nanjing

Two years ago I came to Nanjing in charge of the students of our School of TCM ('MediCina', Milano), that were attending the acupuncture clinics. I had come other three times by myself, but always for acupuncture, while in that occasion I looked for a chance to see how Chinese Medicine treated children, and specifically using tuina.
When I met dr. Yin Ming and saw how she worked I felt that there was really a lot in what was going on in that clinic.
In our School, Paediatrics Tuina is a subject of the third year for Acupuncture students and of the second year for Tuina students, and we also hold short seminars to teach how to treat common diseases to parents and people with no knowledge of TCM.
In the last years I have been treating a number of small patients, with needles, moxa, tuina, and some herbs, but the work with dr. Yin Ming in this month made a real difference, of which I will be grateful forever.
It is just beautiful: her going through Shanghanlun while diagnosing fevers, her talking of Zhou Yi (Yi Jing - Book of Change), the way she moved her hands and smiled quietly, the smoothness with children, the beauty of her technique.

I would now like to share something of this experience: this article takes for granted a knowledge of xiaoer tuina, and it is strictly on the clinical work with dr. Yin Ming.
It will focus on some cases as leading examples of treatment, mentioning comments by the doctor herself.
Thus, manipulation technique and indications of points will not be explained, unless something may appear less straightforward.
A second part of the article will go through the most used manipulations, but again only to point out their use in this actual clinical setting.

The Paediatric Department of Jiangsu Hospital has a ward of 30 beds, an out-patient department with some clinics where they treat with TCM prescriptions, and her clinic, where they use mainly tuina, but also needles and some prescriptions.
Dr. Yin Ming is the Director of the Tuina Paediatric Department, where there are also two other doctors who visit and treat children.
From her telling her life, we learn that she started to study TCM in 1958, at Nanjing University, and Paediatrics from 1963.
In 1975 she studies with dr. Zhao Songzhao, a lady who is the 21° successor of her lineage, and who still comes at the clinic when she feels like, that is quite often. We can see dr. Yin Ming's respect and gratefulness towards dr. Zhao, who - at the age of 82 - is a most lively person.
After Cultural Revolution she is in charge to rebuild-reconstruct the Paediatric Department, and - beside a short time in Shandong Province in 1985 - she has always worked in Jiangsu Provincial Hospital.

September 1999

In four weeks she visited 108 children, mainly for abdominal disorders, infections of the upper respiratory system, myogenic torticolis. Of course during treatment e.g. for torticolis these children may need tuina for common cold or eczema, but the main complaints were:

23 cases of myogenic torticolis
13 cases of diarrhoea
8 cases of accumulation of food - poor appetite
6 cases of vomiting
2 cases of constipation
13 cases of cough
12 cases of fever and cough
12 cases of fever
8 cases of asthma
1 case of common cold
4 cases of nocturnal enuresis
4 cases of mental retardation
1 case of skin disease (4 as secondary symptoms)
1 case of difficult sleep

Some case histories

I chose to use the English terms for the manipulations (the corresponding Chinese terms are found in the paragraphs referring to manipulations), but I kept the Chinese names of points and lines.
To make the reading lighter, I took for granted the Therapeutic Principles.
Sometimes dr. Yin Ming prescribes only one or three treatments, to see how it works.

Diarrhoea
7 months, female, sept 13.
Loose stools with some indigested milk, since two weeks.
The doctor requests a faeces-test: positive ++ for pus cells ….
Diagnosis: deficiency of Spleen and accumulation of dampness

tonifying pi - dachang - xiaochang jing
kneading wailaogong
kneading abdomen
kneading guiwei
tonifying qijie
kneading the back shu points, particularly pi - wei - dachang shu
pinching and pushing jizhu
kneading baihui (briefly)

She comes four times, every day, receiving the same treatment. On the third day stools are normal and the examination of faeces shows only traces of pus cells. The fourth treatment is for consolidation.

Chronic diarrhoea
4 months, female, sept 6.
Watery stools, with indigested milk, 3-4 times per day, since her birth. No fever, no cough, normal urines, no signs of dehidratation.
Diagnosis: deficiency of Spleen qi, with damp-heat in the interior.
Dr. Yin Ming prescribes three tuina treatments.

tonifying pi - xiaochang jing
clearing dachang jing
kneading tianshu
kneading guiwei
tonifying qijie
kneading the back shu points, particularly pi - wei - dachang shu
pinching and pushing jizhu

sept 7: she passed stools twice, less watery. Same treatment.
sept 8: doughy stools (normal for her age). Same treatment.

sept. 20: her grandmother says that the baby had normal stools for a week, until three days ago, and now they are watery, three times per day, with some cough, vomiting once, no fever. The doctor asks if she there had been any change in diet. Since there is none, it might be due to the weather, that had become suddenly cool.
Prescription: the ready-made bags to warm the umbilicus. Tuina for three days.
tonifying pi - shen jing
kneading Yiwofeng - zongjin - zhang xiaohengwen - Erma
kneading feishu
kneading guiwei
tonifying qijie

sept 21: better. Same treatment.
sept 22: normal stools. Same treatment.

Constipation
5 months, male, sept 16.
Since three months glycerine has been used to help evacuation, appetite is not good but not too bad, normal urines, normally soft abdomen at palpation, normal tongue.
He is breast-feeding and taking rice-powder.
Diagnosis: weakness of Spleen.
The doctor prescribes two treatments of tuina.

tonifying pi - xiaochang jing
clearing dachang
pushing liufu
kneading abdomen
kneading guiwei
clearing qijie
clearing jizhu

sept 17: in the morning the baby passed stools without using glycerin.
He did not come in the week-end, but he evacuated daily. He came again every day the week after (five times), to consolidate the treatment:
tonifying pi - xiaochang jing
clearing dachang
kneading abdomen
pushing downwards chengshan BL 57
kneading guiwei
pinching and pushing jizhu
clearing qijie

A modification is done on sept 22 since he has a common cold, with sneezing, some cough, no fever, stools three times in a day:
tonifying pi - xiaochang jing
even method on dachang jing
kneading Yiwofeng - zongjin - zhang xiaohengwen - Erma
kneading chize LU 5 while pressing Erma - zhang xiaohengwen - zongjin
kneading yingxiang LI 20 (very briefly)
kneading abdomen
part-pushing and kneading feishu and the upper back
rubbing xielei
kneading guiwei
pinching and pushing jizhu
The following day he has no more signs of external wind.

Acute vomiting
18 months, male, sept 10.
Vomiting (3 times), diarrhoea (watery stools 3 times) and fever since the day before.
In the past the child had been treated in the same clinic for fever, with good results.
The doctor requires a blood test and a faeces test.
Diagnosis: affection of summer-heat with accumulation of dampness in the interior.

Prescription, for three days: Huoxiang zhengqi san (formula that releases the exterior and resolves dampness, regulates qi and harmonizes spleen and stomach).
One tuina (parents are told to come back in case of need).
kneading Yiwofeng - zongjin - zhang xiaohengwen - Erma
tonifying pi - dachang jing
clearing xiaochang jing ('slapping' the tip)
pushing tianheshui
kneading guiwei
clearing jizhu and bladder channel with guasha ban
squeezing along the same three lines

Chronic vomiting
3 months, female, sept 3.
Vomiting since her birth, 7 out of 10 times of breast-feeding.
Passes stools 1 time every other day. Sleep and spirit are normal.
Sallow complection, white tongue coating, pale tongue proper.
Her weight at birth was 3 kilos, and in three months gained 2 kilos.
Western diagnosis is of cardias spasm.

Diagnosis: accumulation of internal cold, originating from cold uterus (possibly caused by too many ice creams during pregnancy and also now while breast-feeding).
Comment: If there is cold in the foetus (taihan), the vomiting appears immediately after birth, as it might do diarrhoea. During pregnancy diet is very important, the foetus must have the right nutrients, otherwise it will result constitutional cold or heat.

tonifying pi - shen jing
kneading Banmen
counter-round-pushing bagua
kneading yongchuan (right foot)
part-pushing fuyinyang
pushing from the left tianshu downwards obliquely for intestines
kneading guiwei
kneading the back shu points, particularly pi - wei - dachang shu
clearing qijie
pinching and pushing jizhu

The mother is told to avoid cold food.
She came 4 times, every day, same treatment: the fourth day the mother said that the baby the day before vomited only once and passed stools twice.

Vomiting for indigestion
2 and half years, male, sept 1.
Poor appetite, diarrhoea, hiccups since three days. The child had eaten a kilo of shrimps.

Diagnosis: food-accumulation.
tonifying dachang jing
kneading Banmen
part-pushing fuyinyang
kneading zusanli
kneading the back shu points, particularly pi - wei - dachang shu
kneading guiwei
pinching and pushing jizhu

Symptoms are relieved quickly: he came three times, every day, same treatment.

Fever and cough
3 and half years, female, sept 14.
Although she was given antipyretic drugs, fever persists since 4 days, with increasing cough, clear nasal discharge, poor appetite, normal stools but abdominal discomfort.
Thin sticky tongue coating, tongue proper normally red.
Red throat with moderately swollen tonsils. Shen is good.

Diagnosis: invasion of external wind-heat, which attacks Lung, disturbing its normal dispersing function. The external pathogenic factors also cause food-accumulation, that injures the middle jiao.
Comment: differently from adults, in upper respiratory infection of children there is often food-accumulation, phlegm, or convulsions.

Prescription for three days: jingjie, fangfeng, xingren, jiegeng, shenggancao, bohe, pipaye, huangqin, jiazhaoqu…
Tuina one treatment (parents are told to come back if the decoction had no results).

kneading together Yiwofeng - zongjin - zhang xiaohengwen - Erma
pushing tianheshui
part-pushing and kneading feishu and the upper back
clearing jizhu and bladder channel with guasha ban
squeezing along jizhu and bladder channel
patting the upper back

sept 17: the girl has no more fever, the cough is consistently reduced, appetite was good and shen was better.
Auscultation still showed some rattle.
Diagnosis: external factors are relieved, but some internal heat and phlegm persisted.
Prescription: zhimahuang, taoren, xingren, shengshigao, shengancao, zhibei, chantui, fabanxia, huangqin, gonglaoye ((ctr)), qinjiao, huzhang.

flex-extending fingers
kneading chize LU 5 while pressing Erma - zhang xiaohengwen - zongjin
part-pushing tanzhong
part-pushing and kneading feishu - dazhui - and the upper back
patting the upper back

+ plaster on tiantu REN 22 and feishu BL 13

sept 20: she is definitly better, but there is still some cough and phlegm:
flex-extending fingers
rubbing hand
tonifying pi jing
kneading together Yiwofeng - zongjin - zhang xiaohengwen - Erma
kneading chize LU 5 while pressing Erma - zhang xiaohengwen - zongjin
part-pushing tanzhong
kneading feishu

Cough and phlegm
4 years, male, sept 2.
After a fever, treated with western medicines, he still has cough and much dense phlegm. Also: epigastric disconfort, sweating, frequent and loose stools, weak legs. His tongue proper is normally red, the coating is thin, yellow, sticky at the root. Auscultation is negative.
Diagnosis: accumulation of heat and phlegm in Lung and Stomach, after the invasion of the external pathogenic factors.

Prescription for five days: jingjie, fangfeng, baichenhu ((ctr)), xingren, chuanhoupo, pipaye, shenggancao, yuxingca, chenpi, shengjiang, dazao.
Tuina one treatment (parents are told to come back if the decoction has no results)

tonifying pi - shen jing
kneading together Yiwofeng - zongjin - zhang xiaohengwen - Erma
flex-extending fingers
kneading chize LU 5 while pressing Erma - zhang xiaohengwen - zongjin
part-pushing tanzhong
rubbing xielei
part-pushing and kneading feishu and the upper back

Cough and asthma
4 and half years, female, sept 15.
In the last four months she had three severe attacks of asthma, treated with steroids. At the moment her lung showed no wheezing sounds since the last attack (and western treatment) had been two days before, but she has poor appetite and excessive sweating. Yellow tongue coating, tongue tip is very red.
Diagnosis: phlegm affecting the function of Lung, with a constitutional deficiency of Spleen and Lung.

Prescription: I missed it.

Needling sifeng

Tuina once every week (they come from outside Nanjing)
kneading Banmen
flex-extending fingers
rubbing hand
kneading Erma
tonifying pi - shen jing
kneading back shu points
kneading together Yiwofeng - zongjin - zhang xiaohengwen - Erma
kneading chize LU 5 while pressing Erma - zhang xiaohengwen - zongjin
pushing tianheshui

sept 20: the wheezing sound ca be clearly heard, yellow tongue coating.
Prescription: zhimahuang, jingjie, xingren, bohe, shenggancao, huzhang, fabanxia.

kneading Banmen
clearing feijing
counter-round-pushing bagua
douwn-pushing tiantu and tanzhong
kneading fei - pi - shen shu
pinching and pushing jizhu
rubbing xielei

Fever of unknown aetiology
10 years, female, aug 31.
In-patient, with high fever at night, 40°C. It was my first day at the clinic, and she had already had three treatment of tuina: now she has no fever, but still dry stools, poor appetite, yellow coating, dark red tongue.
Diagnosis: heat at shaoyang and yangming.

clearing pi - da - xiaochang jing
clearing gan - xin - fei jing
kneading wailaogong
pushing tianheshui
pushing liufu
kneading tianshu
part-pushing fuyinyang
pinching and pushing jizhu
kneading guiwei
clearing qijie
pushing yongchuan (with guasha ban, towards toes)
clearing jizhu and bladder channel with guasha ban

sept 1: no fever:
tonifying pi - shen jing
pushing tianheshui
pushing sanguan
kneading Erma
kneading tianshu
part-pushing fuyinyang
kneading sanyinjiao
kneading yongchuan

sept 3: fever again, 38.8°C.:
part-pushing and kneading feishu, dazhui and the upper back
clearing jizhu and bladder channel with guasha ban
pinching and pushing jizhu
grasping jianjing GB 21
patting the upper back
kneading Yiwofeng - zongjin - laogong - Erma
kneading c

chize LU 5 while pressing Erma - zhang xiaohengwen - zongjin

Fever, red throat:
2 years, female, sept 20
fever since 5 days, around 38.5°C, normal stools, slightly poor appetite, unchanged after antipyretics, auscultation normal, swollen tonsils, yellow tongue coating.
Prescription: jinlian ((ctr)) tuire chongji (powder to dispel wind and reduce fever)

clearing jizhu and bladder channel with guasha ban
squeezing along dumai and bladder channel
kneading feishu
patting the upper back
grasping jianjing GB 21

I mentioned this case to show a treatment as short as possible (because the girl screamed for the whole time), but normally other manipulations are added.

Myogenic torticolis:

…

Manipulating:

Technique is extremely important, practical teaching is essential: the root of movements, for example kneading (rou), is the same as in adult tuina, the same rithm, the same wave of wrist and elbow. And, since the child is small, it is easy to notice how a wave is passed to the whole body.
There are also specific manipulations that belong more to Paediatric tuina, as the pushing (tui) on the finger-channels (thumb joints must be kept still, the movement comes from wrists).
And this is true for all doctors: even if there are slight differences in their technique, these are only superficial.

She has just perfect manners, children rarely cry or refuse treatment (with the other doctors it goes a bit less smoothly).
If babies sleep, she treats them while sleeping, and sometimes the wave of the kneading puts them asleep. Treatment may also take place during breast-feeding.
If she sees that babies are uneasy she might ask the mother to feed them.
I have never seen her saying to the parents to do tuina at home, but in really chronic cases (as congenital diseases) she said she does teach them.

The usual rule of right and left on hand, forearm, foot for female and male is generally respected (e.g. in torticolis the tonification of Spleen and Kidney channel is done according to the sex, not to the side of the contraction). But manipulations can also be bilateral if there are two doctors working together.
The sequence most of the times is: hand, forearm, abdomen, zusanli, back, but it can easily change and e.g. start from the her/his back if the baby is in the mother's lap.
A complete treatment takes around ten minutes.

Manipulations cannot be too light since they must obtain an effect, but they appear also to be pleasant (even guasha and squeezing, that are definitely stronger, seem to be not too painful). Of course the younger the child, the lighter are manipulations, with a special care not to hurt the baby skin.

The most used manipulation are:

Pushing (tui)

On finger-channels:
Tonifying (bu): from the tip to the root of the finger to tonify (mostly pi - shen - dachang jing).
Clearing (qing): either from the root to the tip (mostly dachang - xiaochang jing) or just using a more 'slapping' movement only on the tips (mostly gan - fei - xinjing).

On lumbar-sacral region:
Tonifying: pushing upwards (shangtui qijiegu).
Clearing: pushing downwards (xiatui qijiegu),

On forearm:
Pushing upwards (shangtui) tianheshui: to clear heat, mainly from external invasion.
Pushing downwards (xiatui) liufu: less used, it clears deeper heat (fu, xue) and toxins.
Pushing upwards (shangtui) sanguan: ….

On back:
To clear heat or relieve the exterior, and it is mostly done using the guasha ban.
Guasha on back has the same function as in adults, but it is used much more often, any time there is an invasion of pathogenic factors: pushing along all thoracic and lumbar spine and lateral to it, with a steady movement and a moderate strenght, so to redden the skin.
Dr. Yin Ming uses a corner of guasha ban, while other doctors may use the long edge of it.

On points:
From tanzhong REN 17 downwards, e.g. for cough
From yongchuan KI 1 outwards, e.g. for long standing fever
From chengshan BL 57 downwards, e.g. for constipation

In some areas it can be:
Part-pushing (fentui):
tanzhong REN 17 and the area of the sternum, mostly for asthma
feishu BL 13 and the upper back, mostly for asthma
fuyinyang (on upper abdomen, along costal margin), mostly for accumulation of food
shouyinyang (on palmar side of wrist), to regulate yin and yang, e.g. for disorders of sleep.

Round-pushing (yuntui) bagua:
On the left hand it is clockwise (shunyun bagua) to go along with the circulation of qi, and counterclockwise (niyun bagua) to counteract a wrong movement of qi, e.g. in case of asthma or vomiting.
It follows the sequence of Emperor Wen of the Zhou Yi (Yi Jing), that is the representation of the trigrams according to houtian (acquired qi), starting from the qian gua (heaven), which is located on the hypothenar, and pushing to kan, gen etc, towards thenar, and so on. The trigrams on the right hand are specular, thus the shunyun and niyun round-pushing is done in the opposite way.

Keading (rou)
It is more a press-kneading (anrou) on points

Points equal to adults points: the most used are:
Feishu, pishu, weishu, dachangshu, tanzhong, yongchuan

Guiwei : one of the most used points, manipulated in any case of intestinal disorder.

Banmen: this manipulation is generally used by dr. Yin Ming instead of the more usual pushing outwards. For accumulation of food, Stomach heat, vomiting.

Wuzhijie: on the dorsal side, but some doctors may rub (cuo) the joints laterally. To resolve phlegm, not only of the heart-orifices but also consistent phlegm in Lung.

Jingning: since it promotes the circulation of qi and dispels accumulations of phlegm and food, it may be used in digestive disorders, vomiting, diarrhoea, cough, asthma.

Erma: much used in case of invasion of pathogenic factors, to strengthen zhenqi, to benefit qi and yang, e.g. in combination with sanguan, or to nourish yin in combination with shenjing.

Yiwofeng: manipulated alone or in combination with three other points, it is used quite often, in any case of invasion of pathogenic factors, to dispels cold and relieve the exterior.

Some points are kneaded together, using two hands. e.g.:

Yiwofeng and zongjin with one hand, Erma and zhang xiaohengwen (or neilaogong if heat is very strong) with the other hand: in order to dispel wind, clear heat, tonify zhenqi, relieve inflammation, benefit Lung. It is used a lot in case of fever and/or cough, phlegm and asthma.

Chize LU 5, while pressing Erma - zhang xiaohengwen - zongjin with the other hand, (holding the arm by the posterior aspect of the elbow): to clear heat, resolve phlegm, benefit the lung. It is used a lot in case of cough, phlegm, asthma.

Kneading abdomen (roufu): it is usually done keeping first and third finger on Tianshu ST 25, or sometimes with flat open palms that cover the all area around the umbilicus (e.g. constipation). There is a clockwise hint in it, but the general impression is of a wave more that of a rotation.

Points on head: dr. Yin Ming kneads them rarely and always very briefly - she used yingxiang LI 20 in a few cases of sneezing and nasal discharge, and baihui DU 20 at the end of treatments for diarrhoea.

Rubbing (cuo)

Hand: it goes generally together with rubbing forearm and flex-extending fingers (qushen shouzi), to improve circulation of qi and blood. Mostly used in cases of phlegm with rattling or hissing sounds in lungs.

Xielei: rubbing downwards the costal region, to resolve accumulation, mostly of phlegm in lungs.

Chest: one hand on anterior side, one on the back.

Pinching (nie)

Pinching the spine (nie jizhu - nieji): one of the most used manipulation, it can be done pinching the tissues vertically instead of the usual 'transversal rolling', to avoid any pain, or to give a lighter stimulation in small babies. It is done going upwards, 6-7 times, and followed by pushing (tui).

Squeezing (jinie)

Squeezing (jinie) along dumai and the internal branch of Bladder channel has a function similar to squeezing or bleeding Xinjiang or Dazhui DU 14: to relieve exterior, clear heat, promote sweating. The pinching is done with thumb and index of the two hands, with enough strength to produce ecchymosis, leaving marks for a few days (in relation also to the amount of pathogenic factor that has to be expelled). If the patient is already sweating enough, there will be only a lighter pinching. When there is fever it is always used, as it is the guasha scrubbing, but it might also be used with no fever, to expel external cold.

Patting (pai)

Mostly used on upper back, to release the exterior and benefit Lung, e.g. in case of invasion of external pathogenic factors and in case of cough, using moderate strength, empty palms.

Beside tuina

Needles:
They are used mostly in some points and in specific cases.

Sifeng:
Generally the four fingers are needled bilaterally, once a week, or 2-3 times a week in more serious cases.
The needling is rapid and superficial, avoiding the visible vessels, and must be followed by a 3-4 squeezing. Some serum will come out, or blood (one has to keep squeezing in serious cases, since the more serious a condition is, the more liquid comes out). In the clinic they use an injection needle.
Sifeng can also be rubbed, without needles, but I have seen it done only twice, in case of poor appetite and lassitude.
Dr. Yin Ming: "In classical texts they are said to be mainly for digestive disorders in children. Therefore they can be used in case of poor appetite, malnutrition, diseases of the intestinal absorption, chronic diarrhoea or constipation. Clinical experience showed that they have good results also in asthma and cough with phlegm: they can resolve phlegm, regulate qi, and act on the immune system. They regulate yingqi and weiqi. Sometimes they can work also in adults, e.g. used 1-2 days before menses in case of dysmenorrhoea."
Beside some cases of poor appetite, I have seen them used, with or without tuina and/or herbs, in case of Lung that does not perform its function of dispersing and descending, with accumulation of phlegm, with a background of constitutional weakness of Spleen and Lung. That is in:
A 2 and half years old boy (sept 1), who suffered of asthma at the age of 6 months (cured with tuina), bronchitis at 18 months. He had fever and took antibiotics 10 days ago, and now cough and phlegm persist, with halitosis, poor appetite, epigastric discomfort, yellow coating.
A 6 months old boy (sept 14) cough and asthma (40)
An 11 months old girl (sept 13), evening fever since 25 days (bronchitis treated with antibiotics), cough and phlegm, poor appetite, auscultation negative.
A 20 months old girl (sept 23) poor appetite, diarrhoea from birth for 5 months cured with tuina (39)
A 3 years old boy (sept 21) fever, cough, asthma, itching at his neck, poor appetite, slight constipation (34)
A 4 years girl (sept 21) poor appetite and bad temper (38)
A 4 and half year old girl (sept 15) with recurrence of attacks of asthma since 4 months, last of which two days before, treated with western medicine, poor appetite, sweating, auscultation negative at the moment. (14)
A 10 years old girl (sept 22) cough and white fluid phlegm, after a week of treatment for fever since a week, cough, yellow phlegm (121)

Shenwen:
Used in all cases of nocturnal enuresis, bilaterally, retaining needles for 20 minutes, every day. Dr Yin Ming says that if this choice does not work, she changes treatment.

The congested vessel on the posterior side of the right ear:
Bleeding with filiform needle: this method is used in all atopic diseases, e.g. in a 5 years old girl (sept 10), for allergic asthma, eczema, cough and moderate wheezing at auscultation.

Other points:
Mostly used in cases of mental retardation:
Dr. Yin Ming chooses points as REN 23, DU 16, DU 15, DU 14, DU 4, SP 6, ST 36, back shu very quickly, without retaining needles, and afterwards she leaves for 20 minutes one cun needles generally on three of the following points: DU 19, DU 20, DU 21, or DU 24, BL 5, or DU 20 and DU 19 with two needles in the two directions, or Du 20 and two of the sishencong.

Prescriptions:
individually designed decoctions are often used, sometimes patent liquid or granulated preparations are also given (formulas will not be discussed in this article, I will only notice that they are used mostly in case of respiratory and skin diseases, almost never in abdominal disorders).
Warm umbilicus powder (nuanqi san):
if the child does not take the decoction, the prescription can be given as stomach-bag (doudu). In two cases it was given as pillow-bag (a 2 months old girl (aug 31), with eye yellow secretion, and a 5 months old girl (sept 6) with eye-lid eczema).

Medicated plaster:
sometimes a 2 x 4 pieces of medicated plasters are used, mostly in case of cough with phlegm, on tiantu REN 22 or tanzhong REN 17, and fengmen - feishu BL 12 - 13, for 12 hours. They may be used also 'locally', e.g. on the area of the lung with the strongest rattling sounds, or in case of hyperostosis of a bone.
They remove blood stasis and promote the free flow of qi (comment: "The moving door will never be eroded by insects").

Moxa:
generally it is not used in the clinic, but the doctor may ask parents to do it at home, mainly for chronic diarrhoea (moxa stick under the umbilicus, keeping a piece of cloth on the skin).

Diet:
If the Spleen does not perform its function of transforming and transporting and cold accumulates in middle jiao, the breast-feeding mother or the child must avoid cold and row food (although the weather is very hot, they are said e.g. not to drink watermelon juice).
Dr. Yin Ming always asks about diet and changes are suggested also if there is diarrhoea or vomiting due to heat, or accumulation of food due to a too rich diet.

General behaviour:
Of course it is very difficult to catch the nuances of patient-doctor relationship. Anyway it is clear that dr. Yin Ming notices if relatives are too anxious and tries to relax them (we must keep in mind that there is only one child in a family, often with four grandparents around). This may be done in a more general way, or on specific behaviours as e.g. saying that two baths a day instead of four are enough.

Western diagnosis:
They always auscultate the chest if there is cough, asthma and/or fever, and might request an X-rays if pneumonia is suspected.
If needed they request faeces tests or blood tests.
Some diagnostic manoeuvres that belong to a common western practice are used: looking at throat and tonsils, palpation of abdomen for enlarged liver or spleen, check of prepuce retraction, controlling signs of dehidratation, etc.