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Acupuncture Today – April, 2005, Vol. 06, Issue 04

A Challenging Pediatric Case

By Ron Hershey, LAc, Dipl. CH

We've all had experiences that push us to what we perceive to be the limits of our abilities as practitioners of Oriental medicine - those cases that seem so challenging, we wonder if we are misleading the patient (and ourselves) by suggesting we might be able to help where scores of other practitioners have failed.

Experience has demonstrated that, in spite of this uncertainty, it is almost always worth a try, especially for a challenging and serious condition.

This was the gist of an internal dialogue in my head as I listened to a mother (who we will call Ava) telling me about her nine-month old baby girl (who we will call Juliet). Ava had heard through the mother of another pediatric patient of mine that my partner Gail Reichstein and I have a sub-specialty in pediatric acupuncture and herbal medicine. Desperation led her to our doorstep.

Juliet's problem was recurrent bronchiolitis, which would begin from a cold and rapidly lead to severe congestion, inability to breathe, hospitalization and steroids. The most recent episode had happened just five days before the little girl's first visit to us.

There was more behind her respiratory history, though. The baby had been born with a faulty heart valve and, the day after her birth, underwent open-heart surgery to correct it. Although she began to suck from her mother's breast during her first day of life, after the surgery and a lengthy recovery in the hospital, she lost the sucking and swallowing ability and was fed through a gastric feeding tube.

On my first meeting with Juliet, she appeared every bit as traumatized as her history would suggest. Fearful and suspicious, she clung to her mother, whimpering, and avoided eye contact. She exuded a dull hopelessness you might see in a child raised in an orphanage. Although I'm accustomed to treating children even younger than this one with needles, it was clear that Juliet wouldn't stand for it. Faced with the issue of giving herbs to a kid who hadn't learned to swallow, I called Subhuti Dharmananda at the Institute for Traditional Medicine to get his opinion on the safety of administering herbs through a gastric feeding tube. After some consideration, he suggested keeping the formula very simple and using a low dose to start.

Devising a treatment that managed to be both simple and yet powerful enough to defuse a potentially dangerous condition was a real challenge. The situation seemed still acute enough that I felt a need to address both the branch (the phlegm overloading the lungs) and the root (the digestive immaturity). We started with two granular custom formula. The first combined er chen tang plus huang qi (dosage: 2/3 grams, three times a day with food). The second was a "bronchiolitis formula" including bai jie zi, dan shen, gan cao, hou po, lai fu zi, qian hu, qing pi, sheng jiang, su zi, and wu wei zi (dosage: 1/2 gram, three times per day). In addition, I advised one acidophilus capsule per day. All of these were to be given through the feeding tube.

At the next visit, Juliet reported having given the herbs faithfully; a feeding tube has the strange advantage of doing an end-run around a child's fussy resistance to the bad taste of herbs. Things had improved, with no more wheezing and just a slight residual cough, but lots of phlegm on awakening in the morning. Juliet's color and behavior both seemed better. With the situation appearing stable, I recommended continuing the regime a few more weeks.

A month passed before I saw them again, at which time the mother reported a difficult few weeks. The baby had had a few cycles of bronchiolitis, which led to incessant vomiting of foul-smelling yellow fluid, dehydration, and passing out. Each time she was taken to the hospital, where her aspirated vomit was suctioned and she was hydrated. Ava reported the baby's breath to be very foul-smelling. I suggested to the mother that she decrease the frequency and quantity of the feedings. She admitted that it was difficult to gauge how much to feed, since the baby's appetite was "out of the loop" thanks to the feeding tube. I also set up a more extensive roster of formulas for a variety of different situations:

Formula Ingredients
Beginning Cold modified yin qiao san: yin qiao san plus ban lan gen, ge gen, huang qin, qian hu, sheng jiang
Bronchiolitis #2 bai jie zi, dan shen, gan cao, hou po, lai fu zi, mai ya, qian hu, qing pi, shan zha, sheng jiang, su zi, wu wei zi, xuan fu hua, zhi shi
Vomiting Formula ban xia xie xin tang + dai zhe shi, gao liang jiang, shen qu, xuan fu hua
Er Chen Tang Plus er chen tang + huang qi

My instructions were to use the er chen tang plus as the ongoing formula, at a dosage of 2/3 grams three times per day with the probiotics, and 25 micrograms of liquid selenium per day for immunity building. I gave Ava a tiger warmer and instructed her to use it on the baby's belly every day.

At the first sign of a cold, she was to take the beginning cold formula - 3/4 grams, two to three times a day. If that proved inadequate, the bronchiolitis #2 formula was to be used at 2/3 grams, three times per day. If vomiting began, the vomiting formula (alone or combined with the bronchiolitis formula) was to be started.

Having this somewhat elaborate game plan with the herbs set up paid off. Over the next four months, Juliet started to get sick a number of times, but each time, the beginning cold formula nipped it in the bud, usually within a day. When I saw her, she wasn't the terrified victim anymore, but a playful coy little sweetheart who played peek-a-boo with me as I listened to her mom recount the news. Ava fed her less and she thrived. Her energy level rose, and she became more vocal about everything (a mixed blessing from her mom's perspective). She developed an appetite and began eating food by mouth. No longer the fearful, shy shrinking violet, she actually yanked out her own feeding tube, which her mom saw as a dramatic flourish.

Subsequently, she has made it through an entire winter without getting more than a 48-hour cold or two. Her mom, who had sworn early on that she couldn't go the experience of rearing another child, is now pregnant with a sibling for little Juliet.

Ron Hershey is adjunct professor of pediatric acupuncture and herbal medicine at Touro College.

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