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Chiropractic Journal of Australia : CJA September 2012
110 Chiropractic Journal of Australia Volume 42 Number 3 September 2012 was physiological jaundice. There was no contraindication to breast-feeding. The infant's mother reported that her son continued to suckle well with proper alignment with her left breast. Two days post hospitalisation, the neonate was cared for on a second visit by the chiropractor, in a similar manner as described above. On this visit, it was noted that the infant’s lower mandible motioned slightly to the left, an improvement on the frst observation. A week after hospitalisation, at a visit to the baby clinic, the infant now weighed 3.45kg. This was a signifcant 400grams increase in weight over a one week period. The parents did not consult the chiropractor in the following weeks. The neonate continued to feed well on both breasts and gained weight. However, on a subsequent visit, several weeks later, the patient’s mother reported the following sequence of events from the preceding weeks. At 6 weeks post-partum, due to the neonate’s continued yellow colour in his facial features, a blood test review was made of his bilirubin levels. The diagnostic suspicion at this time was jaundice from a maternal milk factor and/or blood type incompatibility and/or liver dysfunction. The neonate's paediatrician recommended that for 48 hours, the neonate was to be bottle fed and a new blood test would then be performed. The neonate’s mother also noted that since birth, her baby only opened his bowels every 10 days. The mother had been advised that this was interpreted as "normal" for a fully breast-fed baby. However this was not the experience of this mother with her previous fully breast-fed babies. Her observations were that her babies would defecate more than once a day while being breast-fed. Over the next 48 hours, the mother stopped breast feeding her neonate and changed to bottle feeding. On the advice of the lactation adviser, she continued to express every few hours to keep up her milk supply. The neonate's mother noted that her baby defecated at least 4-6 times over this period. She noted how her son's colour improved in his face over this period. The colour of his faeces refected the yellow colour of conjugated bilirubin. A blood test was then taken and a reduction of bilirubin levels, from 220mg/dl to 90 mg/dl was documented. Based on these test results and the successful intervention with the temporary use of formula feed, the diagnosis provided was breast-feeding jaundice. The reduction and elimination of the conjugated bilirubin was slow to reduce because of infrequent defecation. The neonate was placed back on breastmilk, continued to feed adequately and effectively from each breast. He continued to gain weight thereafter and has been given a good bill of health. His parents continue to present him for chiropractic wellness checks and he continues to have excellent health. DISCUSSION Of the various alternative practitioner-based CAM therapies, chiropractic is the largest and most well established worldwide11 and highly utilised in the care of children.12 In the case presented, the parent utilised the services of a midwife in a hospital setting in addition to chiropractic during her pregnancy and following the birth of her child. This is integrative healthcare as defned by McHughes and colleagues.13 The chiropractor's focus of care was to address the presence of spinal and extraspinal subluxations14 within the framework of a team approach whereby each healthcare professional consulted by the patient's mother was allowed to provide care and make recommendations in the best interest of both mother and child. In such a clinical setting, the attending chiropractor was experienced in her primary task as a chiropractor with knowledge of jaundice in newborns. Jaundice in the Newborn In the 1960s, Arias and colleagues15 and Newman16 independently recognised the association between breastfeeding and prolongation of unconjugated hyperbilirubinemia in the newborn. Initially considered a rare disorder, studies in the United States and the United Kingdom later determined that approximately 1/3 of breastfed newborn infants are clinically jaundiced and 2/3 have signifcant levels of unconjugated hyperbilirubinemia in the third week of life. This is unlike artifcially fed infants of the same age.17 Today, two types of non-organic jaundice are associated with breast-feeding.18 The frst type of jaundice in the neonate is early onset breastfeeding jaundice and attributed to caloric deprivation and/or insuffcient frequency of feeding. It is recommended for the newborn that breastfeeding should be initiated in the frst hour of life, followed by at least 10 to 12 breastfeeds per day for the frst 1 to 2 weeks without any water or other food supplementation. Effective milk transfer from the mother to the infant should result in weight loss from birth of less than 8%. The above breastfeeding practice has been associated with the lowest serum bilirubin concentrations on the third to sixth days of life.19,20 A delay in initiating breastfeeding beyond the frst hour of life, and administration of water to infants either before initiation of breastfeeding or in addition to breastfeeding results in signifcant increase in serum bilirubin concentrations.21 Reduced caloric intake later (i.e., beyond 5 days of life) in the newborn period can also produce marked increases in jaundice, often accompanied by dramatic weight loss, dehydration, and even kernicterus. As in the case report presented, the child will demonstrate lethargy and poor feeding habits with continued high levels of bilirubin. This further suppresses caloric intake and continues a vicious cycle of increasing serum bilirubin concentration. This type of jaundice has also been referred to as non-breastfeeding jaundice. It can be prevented or treated by encouraging mothers to nurse as frequently as possible or address the diffculties involved in breastfeeding (i.e., diffculty or failure to latch). The second type of neonate jaundice is later onset, prolonged jaundice, known as breastmilk jaundice syndrome and is associated with one or more abnormalities in the maternal milk itself. The best explanation for this phenomenon thus far involves the ability of human milk to enhance intestinal bilirubin absorption.17 It is thought that breastmilk jaundice is neither a disease nor a syndrome, but rather a normal developmental phenomenon in the breastfed infant. It is an extension of physiologic jaundice of the newborn.17 Breast milk jaundice syndrome generally needs no therapy if serum bilirubin concentrations remain below 270 mumol/l in healthy full-term infants. When the serum bilirubin concentration is above 270 mumol/l and rising, temporary interruption of breastfeeding may be indicated. JAUNDICE AND CHIROPRACTIC BERNARD · ALCANTARA
CJA June 2012
CJA December 2012