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  Anthroposophical Pediatrics
  

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By: Rene Madeleyn
*Original title: Anthroposophische Kinderheilkunde. Der Merkurstab 1997; 50: 266-80. English by A. R. Meuss, FIL, MTA. Reprint of Chapter 16.04 in Buhring M, Kemper FH (Hrsg). Naturheilverfahren and unkonventionelle medizinische Richtungen (Buhring et al. 1997).

Anthroposophical pediatrics gradually differentiated itself from anthroposophical medicine after the Second World War. Many aspects of Waldorf education have come into it, so its basic character is that of an "educational medicine." Anthroposophical pediatrics started in pediatric practices; inpatient treatment developed when pediatric departments opened at Herdecke Hospital in 1969 and the Filderklinik in Filderstadt in 1975.

This made it possible to maintain regular records in specific fields within pediatrics and assess the value of anthroposophical medicine in this discipline compared to the conventional medical approach. A first overall report on anthroposophical pediatrics was given by Husemann and Wolff (1986), and some guides have been produced mainly for parents (zur Linden 1982; Goebel and Glockler 1988; Stellmann 1989).

Anthroposophical medicine considers typical childhood diseases in relation to typical diseases of adults and the elderly. In childhood, febrile, catarrhal and inflammatory conditions dominate the picture, while in old age the emphasis is on degenerative cardiovascular disease and tumors. Young children tend to develop rickets; older people sclerosis. Taking this point of view, pediatricians can have a powerful influence on the disposition to health or disease for the rest of an individual's life.

In the anthroposophical view of the human being, these groups of diseases are seen as polar opposites. They go with the periods in life when the child takes hold of the body (incarnation) and when the individual gradually leaves the body again (excarnation). If health is regarded as a state of balance between polar opposite diseases, it can be seen why excessive prevention of "physiological" illnesses in childhood may, under certain circumstances, create a tendency to develop diseases specific to old age when this is reached. A good review of the literature to substantiate this and provide empirical evidence is given by Albonico (1996).

Constitutional types
When medicine and education are seen together, the concept of specific constitutions gains special significance. Starting from the anthroposophical view of the human being (see section 16.01 in Buhring et al. 1997) we find that at a given level one of the aspects of the human being is dominant. This is reflected in the child's temperament or in dominance of either the neurosensory system or metabolism and limbs. If the neurosensory system is relatively dominant, the child is "microcephalic," pale, lacking in imagination, and tending to be abstract. If metabolism and limbs are relatively dominant or the neurosensory system is weak, the child will be "macro-cephalic," imaginative, red-cheeked and artistic. The rhythmic system has a balancing and mediating function in this (Steiner, GA 300B). Children with smaller heads tend to be introvert, those with larger heads extrovert. Constitutional treatment includes hot and cold applications, suggestions as to diet (more sugar for small-headed, more salt for large-headed children) and the exhibition of potentized substances (silver and lead).

To deal with one-sided elements in the disposition to a particular temperament, Steiner combined "homeopathic" and "allopathic" aspects, as it were. Teachers were asked to make the melancholic children sit together, and the sanguine, phlegmatic and choleric children sit together. Intense experience of their own temperament has a therapeutic effect in that it calls up powers in the child that help it overcome a one-sided temperament. On the other hand, the teacher should develop enough phlegm in working with a choleric child, for instance, that the child's rage bounces off him completely. Facing a phlegmatic child, a short, controlled choleric eruption on the part of the teacher can create a balance (Steiner, GA 57). The ideal for a school doctor at a Waldorf school is to help the teachers develop a therapeutic attitude. He needs to know the children's state of health and work with the teachers in the child study sessions to establish any one-sidedness in a child's constitution, develop understanding for this, and create a treatment plan. In anthroposophical special education, established by Steiner with a course he gave in 1924 (GA 317), specific constitutional types for children with special needs are considered and treatment strategies developed.

Preventive medicine
Prophylactic vitamin K
Hemorrhagic disease of the newborn due to vitamin K deficiency is rare among fully breast-fed infants (c. 1:10,000). General exhibition of prophylactic vitamin K, currently 2 mg per os at each of the first three health checks, is therefore only justifiable because one gets a high percentage of fatal brain hemorrhages in such cases. So far, it has not been possible to identify the risk of vitamin K deficiency hemorrhages in children who do not belong to special risk groups (premature births, dystrophic children and those requiring parenteral feeding), and it has to be accepted that general prevention is necessary. Parents of newborn infants at the two anthroposophical hospitals in Herdecke and Filderstadt are given a leaflet to inform them of the reason for conventional preventive vitamin K treatment. It is, however, also pointed out that the dosage is so high as to be unphysiological, being 1,000-3,000 times the amount taken in with mother's milk. This fact and some indications that high vitamin K doses may have side effects (Sutor and Kiinzer 1986; Sutor and Goebel 1988; Golding et al. 1992) suggest that it may be advisable to give prophylactic vitamin K in continuous low dosage. This may be done by using a dilute solution of vitamin K. At Herdecke and Filderstadt, all neonates are given one drop (40 mu g) postpartum. The parents are then able to decide at leisure before the second health check if they want to follow the conventional system or choose "natural vitamin K prophylaxis". This means a diet rich in vitamin K for the mother (leaf vegetables, lettuce, carrots) and a teaspoonful of carrot juice given daily from week 2 to breast-fed infants. This more than doubles the vitamin K supply for the breast-fed infant, offering a degree a protection. Even 3 2-mg doses will not give 100% protection. It is also possible to give 40 mu g of vitamin K a week in dilute solution, but this needs to be made up at a pharmacy, as it is not commercially available. From the anthroposophical point of view, carrots give the child the configurative power that is lacking in mother's milk if there is vitamin K deficiency. A tendency to hemorrhage thus may be seen as a lack of configurative power in the blood (Steiner and Wegman, GA 27).

Rickets prevention
Wilhelm zur Linden, the pioneer of anthroposophical pediatrics, established the anthroposophical medical approach to the use of vitamin D for rickets prevention. Working at the Barmen Institute of Pathology, he had collected records of children who had taken harm from the massive doses of cholecalciferol (Vigantol) that used to be given (zur Linden 1964). As a pediatrician, he later saw children given such extremely high doses of vitamin D who developed atherosclerosis and nephrocalcinosis and also appeared prematurely aged in their psyche, as if they had lost some of the powers of childhood. Taking up Rudolf Steiner's ideas on the nature and treatment of rickets and working together with other physicians he developed an anthroposophical approach to rickets prevention and treatment.

Unfortunately, no collection of case records has so far been published to demonstrate the efficacy of the method. An unpublished study by the Dutch pediatrician, Edmond Schoorel, covering 162 children in their first year of life given anthroposophical rickets prevention from 1988 to 1992 showed slight radiological changes in 12 and marked changes in 3 children indicating rickets, but there were no clinical signs. At present, pediatricians working in the pediatric departments of anthroposophical hospitals are agreed that doing without vitamin D generally is not acceptable but that it is possible to use a highly individualized approach to the problem and change to potentized substances especially for breast-fed children and during the summer months. This does require more frequent monitoring, once a month at the time of year when there is less light and every 6-8 weeks in summer. If there are clinical indications to suggest the early stages of rickets, alkaline phosphatase, calcium and inorganic phosphates must be determined to either confirm or eliminate the condition.

Relatively good results have been seen in the outpatient units in Herdecke and Filderstadt with 3-5 drops of Phosphorus 12x given in the mornings, and a good pinch of Apatite 6x or 10x in the evenings. Phosphorus is the only chemical element to release light spontaneously. Its use serves to stimulate the light-processing powers. Potentized Apatite is given to stimulate bone development. Other practitioners have seen good results with Conchae, Quartz, Hypophysis, Stannum, Ferrum and other medicines, in some instances basing themselves on the homeopathic drug picture. Many colleagues use the compound Weleda preparations Phosphorus/Apatite and Conchae/Quercus, but some severe cases of rickets have developed with their use, so it would seem advisable to take a critical view of the use of these preparations and not see them as a specific replacement for vitamin D substitution.

It is important to note that premature infants with a birth weight of less than 2,000 g, infants fed fresh milk preparations (no added vitamin D) or not given cow's milk (almond milk, with no cow's milk added, or soya milk not enriched with calcium) face a particular risk of developing rickets. Sunlight is the most important medicine for rickets. It is enough to have the child's face exposed to the light or a blue sky for 30 minutes daily. If lack of light in winter makes it necessary to give vitamin D for a time, it is usually sufficient to use a lower dose of c. 250 units/day (details and literature in Madeleyn 1995).

Prophylactic fluorine
Prophylactic fluorine in conjunction with prophylactic vitamin D is not considered acceptable by anthroposophical pediatricians. Mother's milk as a model of optimum nutrition contains very small amounts of fluorine. Caries develops not primarily because of fluorine deficiency but because there is too much sugar in the diet. Infants are not in danger of developing caries in any case. Fluorides act to harden the human organism, the extreme case being skeletal fluorosis with calcification of ligaments, involving pain in the bones and signs of paralysis. Natural low-dose fluoride prophylaxis may be given to older children who show a tendency to develop caries or have problems accepting a low-sugar diet. The method is to use mineral water containing fluorine in adequate dosage. The author has published a leaflet on this (Madeleyn 1986a).

Infant nutrition
Anthroposophical views on nutrition are unusual in that there is no standard prescription. Rudolf Steiner spoke of the dangers of too much fat and protein at the beginning of this century. He would never be dogmatic about nutrition, stressing the asocial nature of many special diets and the great social importance of everyone in a community eating the same things. He nevertheless made suggestions on the choice of foods, in individual cases requiring a particular food to be excluded or given in unusually large amounts. An example is meat consumption or vegetarianism.

Experience gained in spiritual and religious streams in Asia has shown that avoiding meat can help meditative schooling. From the anthroposophical point of view, meat ties soul and spirit more strongly to earthly, material conditions. If too much meat is taken, this may encourage premature aging and diseases connected with this, e.g. atherosclerosis, and this is certainly in accord with findings made in recent research into vegetarianism (Section 7.01 in Buhring et al. 1997). Because of this, one avoids giving meat to infants and uses major restraint in this direction with young children. Milk and dairy products are considered good for health by anthroposophists, provided they are not taken to excess. They serve to create the right balance between a state of consciousness that is too earth-bound and materialistic and one that is too spiritualized.

Sugar consumption is differentiated individually, creating a kind of nutritional psychosomatics. It can support our feeling for personal identity in the short term, but excess may trigger addictive phenomena, like those seen with bulimia, and weaken the metabolism. Introvert, melancholic children with low self-esteem should be given more sugar, with extrovert, highly sanguine and hyperkinetic children only limited amounts.

Grains are preferable to potatoes where starchy foods are concerned, the view being that in them, the starch is produced mainly under the influence of the sun or of light, whereas with potatoes the process takes place in the cool, dark earth. Anthroposophists generally tend to eat a vegetarian diet or an "optimized mixed diet," and the recommendations concerning nutrition for preschool and school children are close to those given by the Institute of Childhood Nutrition in Dortmund (Madeleyn 1996a). In arranging meals, special value attaches to a quiet atmosphere with no continuous background noise from radio or television, and emphasis is given to starting meals by saying grace together, giving thanks to the realms of nature that enable us to live. A good collection of recipes for children's meals and the major aspects of nutrition in childhood has been published in German (de Jong 1993).

In this field, anthroposophical medical practitioners fully concur with the research findings made in recent years concerning breastfeeding. At a time when such data were not yet available, Rudolf Steiner spoke of the unique qualities of mother's milk, and, above all, the individual composition relating to the mother's own child. In Germany, the rate of full breast feeding for the first months of life is still undesirably low, a situation that will only be improved by creating close contact between mother and child during the first days after the birth and giving fuller instruction on breastfeeding.

It is worth noting that rooming in was first introduced in the obstetrics department of an anthroposophical hospital at Herdecke in 1969. More than 90% of children born there were fully breastfed when discharged. At the age of 3 months, 58% of the 137 infants seen in pediatric out-patients at Herdecke Community Hospital were still fully breastfed, 20% partly so, and only 22% not at all (Madeleyn 1986a). Investigations by Kaufmann (1992) also showed a breastfeeding rate of over 30% in the 4th month at Herdecke, compared to 10% among children born in other departments. This again indicates that much work still needs to be done to encourage bonding after birth and give breastfeeding instruction.

Anthroposophical recommendations for breastfeeding suggest continuing a little longer than is generally advised. Solid foods should be given in addition from the 6th month, with the infant weaned by about the 9th month. This is the time when children develop teeth, and some degree of release from the close mother-child bond becomes desirable. In our experience children will sleep less easily through the night if nursed beyond this time, though extended breastfeeding may serve a purpose in hyperallergic children.

In contrast to the nutritional advice given for bottle-feeding by other alternative approaches to nutrition such as macrobiotics and Bruker's whole-food diet, anthroposophical guidelines take more account of nutrition science and above all nutrient analysis. They are therefore quite close to the EC guidelines. Industrially-produced powdered formulae are largely avoided, knowing that older children and adults normally reject powdered milk products for reasons of taste, and it may be assumed that young infants in particular have more intense taste sensations and are unable to distance themselves from them, not yet having developed concepts (Ditscherlein 1995; Keller and Maier 1982).

Further research will be needed to establish how far powdered formulae and above all the unpleasantly bitter hydrolysate foods influence the infants' taste instincts for later life. It is evident, however, that the choice of infant foods must be responsibly made. For fresh milk infant feeds, the earlier idea of giving half milk, adding gliadin-containing cereals and sugar but no fats was given up 13 years ago, as the relative proportions of protein, fats and carbohydrates were unfavorable. At Herdecke Community Hospital a system has been developed that makes it possible to prepare the feeds at home and have a composition that is as close as possible to that of mother's milk. It was also decided not to use gliadin-containing cereals in the early months. Infants who are not breastfed are given one third milk, with lactose added for carbohydrate, and almond paste for fat (Table 1). The advantage of almond paste is that the oil it contains emulsifies well and it comes close to the ideal of wholefood added fat. It contains 60-70% high-quality oils rich in mono- and poly-unsaturated fats. Use for feeding atopic children is disadvantageous.

Table 1. Fresh-milk feeds for stage 1 and stage 2

Stage 1 Formula 1
200 ml whole milk
400 ml water
36 g lactose
24 g almond paste

Stage 2 Formula 2
300 ml whole milk
300 ml water
24 g lactose
18 g almond paste
12 g cereal or rice gruel

<br>100 g of the made-up feed contain
Stage 1 feed
protein (g) 2.0
fat (g) 3.8
carbohydrate (g) 7.7
minerals (g) 0.3
calcium (mg) 50
phosphorus (mg) 49
iron (mg) 0.15
linoleic acid 0.43
kcal 74
Stage 2 feed
protein (g) 2.5
fat (g) 3.4
carbohydrate (g) 7.7
minerals (g) 0.5
calcium (mg) 66
phosphorus (mg) 58
iron (mg) 0.18
linoleic acid 0.37
kcal 75
  
An alternative is to use half milk, adding 1.5% germ oil, 3.5% lactose and 2% whole rice gruel. This formula meets the recommendations made by Holle, the firm offering Demeter quality infant foods (Table 2).

It is important to add orange, blackcurrant and carrot juice from week 6. This will balance out the relatively low vitamin C and vitamin A concentrations of fresh-milk feeds. When solids are given from the 4th or 5th month onwards, the change is made from stage 1 to stage 2 (Table 1). The first solids to be given are vegetables, e.g. Demeter carrot puree with 4% cereal and 4% cold-pressed sunflower oil added. From the 5th or 6th month, one more bottle feed is replaced with a cereal and fruit puree, e.g. with wholegrain rusk, 8 g butter and 50 g of milk. The fruit should be fresh if possible, with the mother herself grating the apple, sieving or mashing other kinds of fruit. This is the time when bottle feeds may change to 2/3 milk. In the 6th or 7th months, another bottle feed is replaced, this time with a cereal puree of 2/3 milk and whole grain or a whole milk cereal puree. For exact details see Glockler and Goebel (1988) and Madeleyn (1996b).

Table 2. Comparing mother's milk, Holle bottle feed with rice gruel, and EC guidelines for stage 1 infant feeds.
Ingredients: mother's milk half milk with Holle rice gruel - no juice added up to 3rd month EC guidelines.

Minimum levels
per 100 ml per 100 ml per 100 kcal per 100 kcal 
protein (g)
fat (g)
linoleic acid (g)
carbohydrate (g)
energy (kcal)
calcium (mg)
phosphorus (mg)
iodine (mu g)
vitamin A (mu g RU)
vitamin C (mg)
1.1
4.0
0.4
7.1
71.0
31.0
15.0
6.3
58.0
4.4
1.8
3.1
0.9
7.5
67.0 per 100 ml
55.7
48.8
1.6*
32.6
0.8
 2.7
4.7
1.3
11.3

83.6
73.2
2.4
48.8
1.2
2.25-3.0
3.30-6.5
0.3-1.2
7.0-14.0
60-75
min. 50
25-90
5.0
60-180
8.0
* depending on iodine concentration in atmosphere and soil

Careful rickets prevention must be practiced with all these fresh-milk formulas, as no vitamin D is added to any of them. Careful observance of the recommended method at the two anthroposophical pediatric departments for the last 13 years has meant no nutritional deficits or higher incidence of dyspepsia and colic, with the number of infants born per annum before 2000.

Table 3. Composition of mare's milk (per 100 g)

protein (g)
fat (g)
carbohydrate (g)
minerals (g)
calcium (mg)
phosphorus mg)
iron (mu g)
vitamin A (mu g)
vitamin C (mg)
vitamin B1 (mu g)
kcal
2.2
1.5
6.4
0.36
97.0
50.0
81.0
50.0
11.0
49.0
50.0

Another special feature of the anthroposophical approach is a return to mare's milk, which has a long tradition. In the present Century it has been used mainly in East European countries. Well-documented reports on feeding newborn and young infants with mare's milk have been published by Wiesener and Knobling (1964). Buhlbacker (1995) has reviewed the available literature, including chemical analysis.

Apart from its low fat content, mare's milk is very much closer to human milk than cow's milk. Disadvantages are poor keeping qualities and problems of supply, with the price very high. Table 3 gives a general analysis. Mare's milk is reported to be extremely well tolerated by newborn and young infants. In recent years it has proved a useful alternative to hydrolysate feeds for infants who cannot be fully breastfed. Sensitization of children whose parents are atopic is no problem, as the children will no longer depend on mare's milk later on, and compared to cow's milk its addition to other foods is of no significance.

Remarkably positive results have been seen in children with short-bowel syndrome, intractable diarrhea and cystic fibrosis who are difficult to feed. Mare's milk is not generally recommended for allergic infants but may be used in individual cases of cow's and soya milk allergy when hydrolysates are not tolerated or refused because of the taste. Given temporarily and medicinally it may be used without added fats; otherwise it is necessary to add 2.5% of a germ oil, so that the mare's milk will be closer to human milk in its energy values. Anthroposophical infant nutrition has been discussed in comparison to other alternative approaches by Madeleyn (1996a).

Clinical treatment
Pyrexia and warmth metabolism
A child's warmth metabolism is less stable than that of an adult, with the child needing more warmth and losing it more easily the younger it is. The physical and physiologic explanation lies in the relatively large body surface compared to body weight. In the anthroposophical view of the human being, different temperature levels reflect the differentiated activities of the I organization (Steiner and Wegman, GA 27). Evolutionally, more developed life forms are more independent of their environment where their warmth metabolism is concerned. Anthroposophical physicians consider the instability of the warmth metabolism to be due to the fact that a child only enters gradually into the body with the soul and spirit principle. Being "physiologically premature" (Portmann), humans thus need special care of the warmth metabolism by the parents. Apart from adequate external temperatures, woolen undergarments serve best in this respect. We find allergies developing from contact with wool to be relatively uncommon among the many children with allergy risk we treat.

Pyrexia as a symptom of inflammation is, like the latter reaction, due to a "noxious agent" and therefore a meaningful defense reaction. Children learn to maintain their integrity against the environment with many inflammatory diseases and develop their immune system in the process. According to Spranger (1994), antipyresis is the most common and scientifically also most disputable measure used in pediatrics. In anthroposophical medicine it is only used in exceptional cases, e.g. if there is a threat of seizures developing relative to the absolute temperature level, or in circumstances of severe infection with high temperatures and failure of effective regulatory processes in the organism. Instead of conventional antipyresis, we use physical measures such as wet compresses applied to the lower legs. These are indicated if the legs feel hot and the body needs to discharge heat energy. Other methods are enemas or the use of well-proven natural preparations such as Chamomilla comp, Argentum 30x, Belladonna or Aconitum, depending on the typology. The intention is not to suppress the fever or reduce it artificially but to make the temperature less extreme so that it can be subjectively tolerated.

Febrile seizures
None of the children we have treated in recent years was given long-term anticonvulsant treatment, even with repeated complicated seizures. Antipyretics were only used when children developed temperatures that might cause seizures. Most children would have seizures at the beginning of an infectious disease, when the temperature was rising rapidly; they would then often continue to have relatively high temperatures for some days without developing seizures.

Well-proven medicines that may be given up to hourly to treat pyrexia are Belladonna (usually the 6x), Chamomilla (3x-6x or as Chamomilla comp.®, supp.), Gentians (5% Rh dil.) and Aconitum (6x). There is no acceptable alternative to the use of diazepam-rectiolene which is recommended in conventional medicine to cut a seizure short. Our greatest problem in dealing with febrile seizures is the parent's anxiety. This is understandable as many parents who are unprepared for such a seizure instinctively feel their child is going to die. Fortunately, the scientifically well-substantiated view that most cerebral seizures do not cause brain damage is gradually gaining acceptance (Holmer 1991).

Classic childhood diseases
One of the major differences between anthroposophical and conventional medicine is the view taken of these diseases. Their meaning is not considered in conventional medicine, and the aim is prevention in order to avoid possible complications. In the case of measles, the WHO's goal was total eradication. On the basis of his spiritual scientific investigations, Rudolf Steiner stated that the purpose of childhood diseases was to enter into a critical conflict with the hereditary powers in the body and overcome them to some extent (Steiner, GAs 314, 319).

The real noxious agent triggering the disease is seen to be not the pathogen but the inherited body which is experienced as foreign and therefore a "noxious agent" by the child's soul and spirit nature. This approach is supported by an observation made by parents and physicians, which is that children often take a real step forward after a childhood disease and appear more independent and mature than before. Research is needed to make a more systematic study and critical assessment of this. A number of anthroposophical pediatric practices are currently asking the parents of children with measles to fill in a questionnaire. The clinical approach to childhood diseases is summed up in Table 4.

Table 4. Anthroposophical treatment of childhood diseases

Medical treatment – External applications

Rubella: does not normally require treatment;

Whooping cough: Pertudoron® 1 and 2 in alternation; clinical experience has shown single preparations given on indications based on the homeopathic drug picture (e.g. Imhauser 1975) to be more effective, warm lavender oil packs, moist and warm lemon chest packs;

Measles: Pulsatilla 6x; if severe, Aconitum 6x or Pneumodoron® 1 lavender oil chest packs;

Chickenpox: if high temperature and severe case, Belladonna 6x and Rhus toxicodendron 4x WCS Dusting Powder®, Tannosynt® (tannic acid) lotion;

Scarlet fever: Apis/Belladonna pilules (Wala), Erysidoron 1 (Weleda), Cinnabar 20x, Vaucheria 3x

Mumps: Apis/Belladonna pilules, or Erysidoron 1 Archangelica ointment 10% (Weleda) applied to swollen glands

Scarlet fever as a streptococcal infection is always treated with penicillin in conventional medicine, but anthroposophical physicians usually avoid this. The author has published a collection of cases from the Herdecke Community Hospital pediatric department (Madeleyn 1986c), and today the streptococcus study at the hospital covers more than 1,000 case records from medical practices and hospitals. While not prospective or randomized, it does permit a cautious assessment as to when and to what extent it is possible to treat these conditions by anthroposophical methods, avoiding the use of penicillin. The period of being confined and isolated should be at least 3 weeks. The medicines listed in Table 4 are given 3 times daily to one hourly, depending on severity, using 3-8 drops or 3-8 pilules depending on the child's age.

Immunization
It will be evident from the above that medical practitioners working out of Anthroposophy take a critical view of immunization, especially against the classic childhood diseases. On the other hand, its usefulness is not denied out of hand, and efforts are made to talk to the parents and come to an individual and differentiated decision on the issue. Details may be found in a leaflet and in A Guide to Child Health (Glockler and Goebel). Diphtheria, tetanus and polio immunization is usually given at one year, these being diseases where one cannot say that children usually go through them without suffering harm so that the responsible attitude would be to let them go through them.

Girls should be vaccinated against rubella at 15 unless protected by having the disease naturally. The new acellular Pertussis vaccines have distinctly fewer side effects than the old cellular vaccines but will give no protection in the first three months of life, which is when whooping cough is most dangerous. Diphtheria, tetanus and polio immunization is given at a later date to allow the infant to put all his energies into development. Any risk from this delay seems improbable, and this also makes it possible to detect or exclude more serious developmental disorders in the first year, with immunization excluded as a causative factor.

The success of vaccination against systemic Hib infection has been evident from the reduced incidence of the infection, with the vaccine relatively well tolerated. A critical comment that must be made is that this immunization does not affect a child's disposition to meningitis, which may, indeed, increase when one pathogen is eliminated by immunization. Such a trend has not yet shown itself in Germany.

The incidence of viral encephalitis has shown a definite increase between 1980 and 1990, in spite of a reduction in measles encephalitis due to measles immunization. This would appear to indicate that there has to be a disposition before a particular infection can occur, so that individual pathogens become less significant (Windorfer and Gruneweg 1993). As a result, we do not yet have consensus on the need for Hib immunization among anthroposophical pediatricians. All issues concerning immunization are regularly reviewed by a group of physicians.

Treatment of the most common infectious diseases:

URI
These are common infections, and anthroposophical medicine offers a considerable armamentarium in this area. Spontaneous recovery tendencies are good, which helps our clinical enthusiasm. Part of our advisory work is to help parents use the "family medicine chest" for self-medication. Apart from original approaches to treatment such as exhibition of Pyrites and Cinnabar to treat bronchitis and tonsillitis (Steiner and Wegman, GA 27), much of the potential offered by traditional phytotherapy and homeopathy is also utilized (Table 5).

Table 5. Anthroposophical treatment of URIs

Rhinitis
Physiological saline as nasal drops, Euphorbium comp. as nasal spray, Oleum rhinale® and Nasal Balm mild® for dry rhinitis.

Pharyngitis and tonsillitis
Apis/Belladonna (pilules), Erysidoron® (drops), Cinnabar 20x (tablets), moist, warm lemon compresses on throat.

Bronchitis
Cough tea with thyme, petasites, coltsfoot and ribwort plantain, lavender oil chest packs, Plantago Bronchial Balm' applied to chest, Pyrites (2x-6 x, Weleda) by mouth, Cough Elixir, homeopathic single medicines, e.g. Bryonia or Tartarus stibiatus.

Sinusitis
Mustard powder foot bath, Silicea comp. pilules (Wala), Argentum Berberis comp. (Weleda).

Pneumonia
With the treatment of pneumonia, it is important to have close supervision by a physician with experience in anthroposophical medicine. Self-medication must be avoided, and if clinical monitoring is not available, the indication for antibiotics must be on a broader basis. Purely anthroposophical and natural medical treatment of pneumonia is contraindicated with newborn and young infants, immunosuppressed patients, e.g. those receiving chemotherapy or corticosteroids, children with cystic fibrosis and in cases of severe bacterial pneumonia. Treatment without antibiotics sometimes, but not always, calls for a little more patience, with the temperature going down only on the 5th to 10th day of treatment. The main medicines generally used are Aconitum, Bryonia, Phosphorus and Tartarus stibiatus (e.g. as Pneumodoron 1® and 2). During the highly febrile initial stage, high potencies of silver are given in addition (e.g. 1 ampule of Argentum 30x/Echinacea 6x by injection or by mouth, given twice). At the hepatization stage Ferrum (e.g. Ferrum sid. 6x trit.) has proved helpful. The first four medicines are given in alternation (5-8 drops) at hourly or 2-hourly intervals.

It is often helpful to humidify the atmosphere. Inhalation (e.g. Emser Sole - natural saline containing sodium, potassium, chloride, sulphate and Nbicarbonate) helps mucolysis, externally quark (soft cheese) chest packs give relief especially with high temperatures, to be followed later by lavender oil packs to assist resolution and act as a sedative, mustard packs for their derivative effect, and ginger packs for their warming effect as the temperature goes down.

Otitis media
No antibiotics are needed in the majority of cases showing gradual transition from syringitis to serous and purulent otitis. If a child presents as seriously ill, weak, with a temperature persisting for more than 5 days, a critical assessment must be made to determine if it is possible to continue without antibiotics. Widely-used medicaments are Levisticum (Rh 3x dil., Weleda), Apis/Belladonna pilules (Wala), and Pulsatilla (2x-6x). Warm chamomi bags and onion compresses are applied externally to the affected ear. Onion compresses in particular have such a rapid effect that they have convinced many parents of the potential offered by natural medicines. They are much used as a family remedy in cases of earache.

Pseudocroup
The condition can always be treated without recourse to the corticosteroids used in conventional medicine. These shorten the period of illness but do not deal with the respiratory distress requiring incubation in severe cases. A collection of case records presenting and explaining the treatment used in anthroposophical medicine has been published by the author (Madeleyn 1986b).

Apart from Bryonia/Spongia comp.° and Pyrites 2x given by mouth, excellent results are seen with Gencydo° 0.1% and Quartz 20x ampules (OP Weleda). Lavender oil chest packs are excellent for their relaxing effect. Cold air inhalation is given in hospitals using an ultrasound nebulizer. At home, humidification or fresh air maybe used as available. If the condition is severe (stages 3 and 4) and does not improve with the above methods, Micronephrin® inhalations may be given under clinical supervision.

Urinary tract infections
It is remarkable that urinary tract infections hardly ever develop in the course of infectious diseases. This indicates that with them, even more so than with infectious diseases, the individual constitution plays a role so that treatment must aim to strengthen a weakened organism. Antibiotics certainly do not do this but nevertheless are usually indispensable in the treatment of urinary tract infections as well as malformations and reflux.

Some positive results seen with problem patients who presented with frequent recurrences justify anthroposophical adjuvant and follow-up treatment. Equisetum arvense, well known from popular medicine, is an important medicament; spiritual science shows a relationship between its generative powers and those of the kidney organization. Equisetum is used as a tea, in warm compresses applied to the kidney region, and in low potencies given by mouth.

Other medicaments widely used in our hospitals are Carbo pteridii aquilini (4x-6 x trit.), Teutcrium scordium 1x (dil.), Lachesis (8x-20x, esp. in acute situations), and for cystitis above all Cantharis comp. pilules (Wala). External applications are warm eucalyptus oil packs (10%) on the bladder and kidney region, and ointment dressings using Argentum Ointment (0.4%). Bed rest was more firmly insisted on in the past, and it is certainly possible that this played a role in the natural medical and anthroposophical treatment of urinary tract infections and made it possible to achieve the results older colleagues report seeing without use of antibiotics.

Gastroenteritis
Apart from the usual dietetic measures, mare's milk has proved particularly effective in persistent cases. Medical treatment is not required in uncomplicated cases. Severe and protracted situations are treated with various bitters (Geum urbanum, Gentians), Stibium arsenicosum (6x trit.) in cases of circulatory weakness or salmonella infection, or Veratrum alb. (4x trit.) as "plant arsenic." If vomiting occurs or ketonemic vomiting is a dominant feature, frequent doses of Nux vomica (4x-6x dil.) and Ipecacuanha (4x-6x dil.) can work wonders in my experience. Given under clinical supervision they have saved many a child from needing infusions. With electrolyte imbalance, acidosis or shock syndrome, one takes recourse to the well-proven conventional emergency measures.

Epilepsy
Rudolf Steiner presented the spiritual scientific view of epilepsy in a course given for special education teachers (GA 317). During sleep, the astral body and I organization, i.e. the soul and spiritual principles, are not actively involved in the body but in the world of the spirit which is not perceptible to the senses but can be accessed by those who have developed higher faculties. The result is absence of consciousness. When the individual wakes up they intervene in the living body again, perceiving the outside world in daytime conscious awareness. This process is incomplete in someone with an epileptic constitution. The soul and spirit principle gets caught up, or is "held" in the organs, above all the brain. The evident result is paroxysmal disorders of cerebral function. A mild form of this exists with any muscular spasm, a modified form with hyperventilation tetany.

Epilepsy affects the relationship between body and conscious mind (soul and spirit) at an existential level. Epileptics therefore see themselves as particularly stigmatized. It is not for nothing that epilepsy formerly had a religious connotations. Merely to speak of abnormal electrical discharges in the brain as the cause does not do proper justice to the nature of the disease.

A review of anthroposophical publications on understanding and treating epilepsy, including a collection of case records, has been published by the author (Madeleyn 1990). In this clinical trial, 36 of 125 children with epilepsy were treated without anticonvulsants in 1988 and 1989. The usual anticonvulsants thus still had to be used in the majority of cases. It is worth noting that several children with infantile spasms showed excellent improvement or became free of attacks on anthroposophical treatment only; some of them had not previously responded to conventional anticonvulsant treatment. In the group of benign focal epilepsies, the prognosis is favorable; and in conventional medicine, too, anticonvulsants are not always used. We saw 5 of 8 children become free from attacks with anthroposophical treatment. 9 of 16 children with primary or secondary generalized grand-mal seizures became free from attacks with anthroposophical treatment, though these were children with relatively rare or milder seizures. No convincing results were seen in children with absences (petit mal seizures), while 2 of 4 children with myoclonic or myoclonic astatic seizures became free from attacks without being given anticonvulsants.

A window of opportunity for purely anthroposophical treatment was given when seizures did not respond to conventional treatment, or the side effects of anticonvulsants were too severe compared to the frequency and severity of seizures. It is important to have a physician who has experience in the field. The types of seizures and evolution vary so much that one must all the time weigh the potential and limits of conventional anticonvulsant treatment against those of natural and anthroposophical treatment. The two may also effectively complement one another. The main anthroposophical medicines used to treat epilepsy are Belladonna, Hyoscyamus, Viscum, Plumbum, Carbo and Bryophyllum argento cult.

Development disorders
Anthroposophy offers an approach to special education and because of this the treatment of developmental disorders also plays a special role in anthroposophical pediatrics. Only some major aspects will be considered here. Readers are advised to consult the extensive literature on the subject (e.g. Bort et al. 1989).

The approach to handicapped children focuses on the view that the spiritual aspect of the child, his individual nature, cannot be sick but does not come to full realization because the body is sick. Handicap is not in itself seen as a pointless misfortune but an incomplete incarnation in the sequence of repeated lives on earth, its significance only becoming apparent if a wider view of destiny is taken. This explains, for instance, why anthroposophists are against termination of pregnancy if the child has Down's syndrome. The approach establishes a deep connection with the children one cares for, and this can be experienced in anthroposophical special education centers such as Camphill places, day centers, kindergartens and schools within the special education movement.

A special feature of the work in this sphere is the emphasis on a rhythmic element in the day ("morning meeting," "evening meeting"). Religious and artistic elements play an important role as they mediate between the world perceived by the senses, and the world beyond sensory perception with which the spirit of a handicapped person remains more strongly connected. Remedial gymnastics based on neurophysiologic aspects is given if there are cerebral movement disorders. It is important to emphasize that developmental steps and movement patterns are not imposed but developed in a joyous, playful atmosphere.

Another comprehensive measure to promote development is eurythmy therapy, an integral part of anthroposophical treatment. It uses gestures reflecting the evolution of sounds, rhythms, spatial forms and musical movement forms. The child imitates the movements. If a child is unable to move, the forms act through the perceptive faculties, or the therapist guides the child's limbs. Eurythmy therapy is a clinical modification of eurythmy as an art form. This new movement art serves to present speech and music. The elements of eurythmy therapy were evolved in the eurythmy therapy course (GA 315).

Eurythmy therapy addresses motor functions, sensory perception, speech and musical elements, which makes it excellent for treatment of the frequent cognitive and motor integration disorders seen in handicapped children and also certain performance deficits, hyperactivity, etc.

Chirophonetics is a special method developed by Alfred Baur to help speech and treat speech disorders. The therapist makes the sound movements on the child's body using a massage-like technique (Baur 1989).

Other art therapies such as music therapy, painting therapy and speech formation are also used. Wegman and Hauschka rhythmic massage serves to develop a healthy experience of touch, a feeling of inner well-being in the sick body, relaxing and strengthening the muscles.

The aim of medical treatment is to stimulate the generative powers of the nervous system (Arnica, Quartz, organ preparations) or address constitutional bias. Homeopathic medicines are used according to their drug pictures. With some degenerative neurological diseases such as leukodystrophies we have observed a slowing down of the pathological process (and hence of deterioration) with anthroposophical medicines.

Atopic diseases
The incidence of these diseases is showing a steady increase, with no convincing explanation given in conventional medicine. There is clearly a close connection with lifestyles in highly industrialized countries and the level of education, whereas atmospheric pollution plays more of a subordinate role. Inadequate training of the immune system also appears to favor the disposition. We are under the impression that frequent immunization, high antibiotic consumption and a reduced number of febrile diseases correlate with increased tendency to develop atopic disease.

From the anthroposophical point of view, the threefold nature of the neurosensory system as the basis for perception, the forming of ideas and coping with stimuli, and the system of limbs and metabolism as the basis for exerting the will and for metabolic function are in polar opposition. The astral body and I organization enter deeply into limbs and metabolism, withdrawing from conscious awareness, as it were. In the neurosensory system, they are essentially acting freely. The rhythmic organization (heart and respiration) as the vehicle for the emotional life acts as a mediator between the opposites.

An atopic constitution exists when the neurosensory system is overstressed or hyperactive and there is a relative weakness of the system of limbs and metabolism. In many schools of natural medicine atopic conditions are considered to be due to metabolic weakness, and treatment is via the metabolism. This would explain why these conditions are mainly seen in people who do mental work. For example, in Switzerland the incidence of hayfever is 1% among rural workers and 20% among intellectuals. Staehelin has considered this in detail (1961). Relatively many parents have the feeling that atopic diseases are not adequately understood by conventional medical practitioners, who consider them incurable, while treatment, often purely symptomatic, has many side effects. They therefore take their children to an anthroposophical physician.

General dietary advice is to give a balanced wholefood diet with little animal protein. Milk products are not banned if tolerated. Sugar consumption is reduced, and synthetic food additives such as preservatives, colorants, etc. are best avoided. A reduction in sensory stimulation is favorable and important for the above reasons (television viewing, videos, cassettes, computer games, etc.), with children encouraged in creative play (Waldorf education). Art work and art therapies as well as eurythmy therapy strengthen the rhythmic organization and thus help to create a better balance between neurosensory system and system of limbs and metabolism.

Neurodermatitis in children is generally treated without recourse to corticosteroids. We use ointments with various plant extracts, e.g. Equisetum 10% oily extract, Solanum dulcamara and Lysimachia nummularia (Dermatodoron Ungt.). Oral medication serves to strengthen metabolism (Cichorium, Gentiana, Taraxacum stanno cult. Rh D3) or counteract the chronic inflammatory process in the skin (Quartz, Thuja). It can be a real challenge to relieve the often tormenting pruritus. Bryophyllum 50% trit. or Urtica dioica ferro cults Rh D3 (Weleda) help in some cases. Elimination diets for a week or two followed by exhibition of specific foods can assist in formulating an individual diet plan if the history suggests food allergy. Treatment is protracted and requires much patience, even in anthroposophical medicine, especially if the condition is severe.

Unlike neurodermatitis, childhood asthma may involve life-threatening episodes. This is the domain of conventional medicine with its whole spectrum of available treatments. The situation is different with regard to longterm treatment. Evolution is distinctly less good with symptomatic treatment using beta2-agonists and corticosteroids. Sodium cromoglycate, being derived from a phytotherapeutic drug and having few side effects, is probably the most acceptable. Clinical use of the potential offered by anthroposophical medicine has, in our experience, given considerable improvement, making it possible to discontinue both corticosteroids and beta2-agonists. It was interesting to note that some patients did better on purely anthroposophical treatment than with conventional treatment.

The most important treatments were home-made oak bark tea in the mornings, speedwell tea at night as basic medication (tannins and bitters as active principles; Steiner GA 314). Cuprum aceticum 4x and Tabacum Rh 6x are given by mouth especially if there is obstruction. Other obligatory elements are Levico (3x ampules), Gencydo® (0.1-7% ampules) and Quartz 20x (ampules) inhalation, chest packs with lavender oil, lemon, ginger or mustard depending on the psychic constitution, warmth metabolism and individual tolerance.

Art therapy and educational psychotherapeutic guidance help the child to harmonize the breathing process by influencing the life of feeling. Objective monitoring of evolution is by means of peak flow determinations.

Gencydo®, a quince and lemon preparation, is also a major medicine for childhood hayfever. Apart from inhalations, which should start 4-8 weeks before the season, s.c. injections (often painful and only partly suitable with children) may be considered, as well as use in eye drops and nose drops. Other medicines are, again, tannins, bitters and potentized quartz.

Rheumatic conditions in children
Clinical experience treating about 30 children with rheumatic conditions showed that anthroposophical and homeopathic treatment, eurythmy therapy and a vegetarian wholefood diet resulted in marked improvement or complete recovery in about a third. It was possible to discontinue NSAIDs in some cases and avoid the basic immunosuppressant treatment which had been proposed.

Chronic inflammatory diseases of the bowel
Systematic discussions of the nature and treatment of these diseases, with case records for adults, are available in the anthroposophical literature (Schikarski 1993). Generally speaking they also apply to childhood. Corticosteroids and anti-inflammatory agents (mesalazine, sulphasalazine) are indispensable above all if the condition is severe. Chronic inflammatory diseases of the bowel respond also to art therapies and eurythmy therapy, above all on account of the known psychosomatic basis and/or one-sided personality structures. With children it is important to include the family and social environment to make the approach truly holistic.

Cystic fibrosis
In anthroposophical medicine, efforts are made to strengthen the lung organization and counteract the slowly progressive fibrosis, which is a form of premature involution. Adjuvants to be considered are, above all, Prunus, Ferrum and Phosphorus, all in low potency. Marked improvement in quality of life and survival are seen with conventional treatment (antibiotics, enzyme substitution) and good physiotherapy. Negative experiences make it necessary to warn explicitly against treating manifest pneumonia in cystic fibrosis patients purely by natural medicine and without antibiotics. Eurythmy therapy can stimulate the breathing process and strengthen the child's general condition.

Endocrinology
No data are available in anthroposophical medicine about the treatment of juvenile diabetes and other endocrine disorders requiring conventional substitution treatment to suggest it is possible to do without hormone substitution where indicated. Adjuvant treatment seems indicated to stimulate residual glandular function or prevent complications (e.g. polyneuropathy or retinopathy with diabetes). Rosemary baths are given in cases of diabetes mellitus; oral medication may include bitters (e.g. Absinthium) and Phosphorus (6x), the aim being to strengthen an I organization that is not sufficiently controlling sugar metabolism (Steiner and Wegman GA 27).

Neonatology
Neonatology departments with relatively limited facilities for intensive care exist at Herdecke and the Filderklinik in Filderstadt. In many respects, the approaches developed out of the anthroposophical view of the human being are similar to those used in Marina Marcovich's "gentle care for the premature." This is briefly outlined in the book, Anthroposophische Medizin (Glockler et al. 1993). A valuable addition that infants evidently find agreeable is gentle, whole-body massage with a mixture of almond oil, a drop of rose oil, Blackthorn Flower Skin Oil (Wala) or Wild Rose Oil (Weleda). Children with birth trauma are given Arnica (Rh 6x) by mouth, and in case of infections adjuvant Argentum 30x/Echinacea 6x and Carbo 30x. For treatment of the fresh-cut cord, WCS® Dusting Powder and Calendula Essence have been tested, as well as in comparative trials (WCS®, Janke 1994). Anthroposophical medical measures are less to the fore the greater the need for intensive care.

Oncology
Conventional medicine undoubtedly has made great advances in oncology, but parents of children with neoplasms frequently look for help from anthroposophical medicine and other forms of natural medicine. Apart from a number of potentized medicines, mistletoe plays a central role in the treatment of tumor patients. Details of this are given in the relevant chapter in this book.

Over the last 15 years, systematic clinical experience has been gained above all by ChristophTautz at the pediatric department of Herdecke Community Hospital (Plessen 1996). Tautz and others working in pediatric oncology have now treated more than 400 children using the anthroposophical medical approach. It has been found that one cannot, as a rule, do without surgical interventions, chemotherapy and radiotherapy that are likely to be effective. Anthroposophical medicine does, however, represent a definite addition to the armamentarium. The aim of using it in adjuvant and follow-up treatment is to reduce the tendency to tumor development in the organism, support affected organ functions, and reduce the often severe side effects of conventional treatment. It is evident that children are subjectively better with this kind of adjuvant treatment, showing better tolerance of a course of chemotherapy (comparison made also in the same patient), and that appetite, autonomic rhythms and powers of resistance show a more rapid return to normal. In some cases, e.g. brain tumors where no further conventional treatment is available, purely anthroposophical treatment has resulted in remarkable remissions.

A pediatric oncological quality group meets for the critical assessment of clinical results and sharing of experience in the German Anthroposophical Medical Association (contact: Christoph Tautz). The work done at Herdecke Community Hospital has resulted in a book with reports from parents (ed. Tautz & Grutgen 1990).

Psychosomatic
Anthroposophical medicine is inherently holistic, so that psychosomatic illnesses play a relatively large role in both hospital and practice-based work. Three syndromes or symptom complexes are discussed in more detail below:

Sleep disorders
These are not infrequent, especially in infants and young children, and can be a major challenge to parents and pediatrician (referring to sleep disorders with no appreciable organic cause). A child lives wholly in his environment with soul and spirit, sharing in the soul quality of the environment. In anthroposophically-extended pediatrics we therefore consider it most important to include this environment in looking for the causes.

The body is regenerated in sleep. The powers of conscious awareness, which are active during waking hours, have a destructive effect, and this causes tiredness. Young children need more sleep than adults because they use up more of their constructive powers in growth. We see a greater incidence of sleep disorders when young children are exposed to too many stimuli (travel, moves, media) or a tense atmosphere (e.g. parental strife) or have too much attention focused on them. The mother's intense feeling that the child ought to be asleep will prevent sleep just as adults who have problems going to sleep must not try to force it but "let go".

Night-time rituals that make a child dependent on its parents can also contribute to sleeping-through problems — giving a bottle, or a dummy, always letting the child go to sleep at the breast, taking him from his cot and carrying him about for long periods, etc. If we see sleep as a condition in which the child returns to the world of the spirit where he had been before he was form, we can create a special mood before the child goes to sleep to mark the transition — saying a night-time prayer by candle light, singing a song, later on to read a story, and so on.

In many cases, treatment consisted mainly in creating more distance between parents and child, helping parents to feel confident that the child can go to sleep on his own, to show oneself when he cries at night, comfort him, give a brief caress but not take him out of his cot. Medication may give support but should not be the only solution to the problem. The main medicines are Avena sativa comp. dil. (Weleda), Avena comp. pilules (Wala) and Bryophyllum, either 50% (trit.) or as Bryophyllum argento cult. (Rh D3 dil., Weleda).

Enuresis nocturna
After exclusion of purely organic causes or the delayed maturation which is hereditary in some families, emotional causes of bedwetting have to be considered. In the special education course (Steiner, GA 317), bedwetting is referred to as a symptom of childhood hysteria, a form of emotional hypersensitivity that leads to anxieties and depressive moods. Steiner suggested Hypericum (2x) by mouth and Hypericum oil (25% Oleum) applied to the bladder region and thighs. This herbal antidepressant was known long before imipramine hydrochloride was introduced as a conventional antidepressant for the treatment of enuresis.

Apart from working through any conflicts that may exist between the parents or with parents and child, in family therapy and simple behavioral measures such as waking the child at night to go to the toilet and morning rituals such as painting a sun if he has been dry and rain if wet, offering a small reward if there are a sufficient number of suns, eurythmy therapy proves successful in many cases.

Eating disorders
Anorexia and bulimia appear to be on the increase in western, industrialized countries. It is not simply a matter of loss of appetite or ravenous hunger, but false directions taken in dealing with conflict situations in a world where the inner life is getting increasingly complex.

Karl-Heinz Ruckgaber and the Klinik have developed a psychosomatic concept where the key theme is that anorexic girls, who tend to be anxious and sensitive, are afraid of relating to the material world. With bulimia they noted a matter-bound enhanced greed for life, which also is more than can be borne. Both conditions develop into severe addictive habituation with the well-known dangers for body and soul.

The only effective way of dealing with this is a holistic approach, on the one hand strengthening the body and at the same time showing understanding, as a fellow human being, for the addictive confusion in mind and spirit as the young person seeks the true ideals of youth. Management includes guidance in a group sharing a daily program (morning meeting, shared meals, going for a walk, evening meeting), psychotherapy and/or family therapy, external whole-body applications, eurythmy therapy, painting therapy, music therapy, speech development and Bothmer gymnastics.

Follow-up examination of 79 former anorexia patients treated by this method 12 years earlier (results not yet published) showed good recovery in 53%, moderate recovery in 30% and poor results in 14%. Two patients had died. Compared with international reports these figures may be rated more favorable.


Rene Madeleyn, MD
Filderklinik
Im Haberschlai 7
D-70794 Filderstadt-Bonlanden
Germany

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