JULIE MAYER HUNT, D.C., D.I.C.C.P.

 Objective: To present a case study of a three-month-old female breast-fed infant with irregular bowel habits since birth. This article will discuss observations of this case while under chiropractic care, and the subsequent return of healthy bowel function.

Clinical Features: A three-month-old female breast-fed infant presents with bowel dysfunction since birth. The parent reports the patient does not move her bowels without assistance of suppositories. The frequency of bowel movements ranges from one week to ten days.

Intervention and Outcome: Treatment is initiated and over the next five weeks the patient is adjusted utilizing the Laney instrument. The patient's bowel function is restored and no longer requires assistance in evacuation of her bowels.

Conclusion: This is a case where upper cervical adjustments were given to an infant with bowel dysfunction. Care and treatment for this patient was approached with the hypothesis that reduction of the upper cervical subluxation complex may result in improved function of the gastrointestinal tract.

Key Words: constipation, Hirschsprung's disease, chiropractic, upper cervical

INTRODUCTION

Constipation is difficult to define objectively due to the wide range of bowel habits that are considered "normal." In adults, the condition is typically described as having less than three bowel movements in a one-week period. ^1,2 However, bowel habits vary greatly for each individual, their age and their diet.^5,6,7 Other criteria should be examined in order to accurately determine if bowel habits are within normal limits. These should include a change from the patient's normal pattern, hardness of stools, the need to strain and the inability to evacuate contents completely. ^1,2

Hirschsprung's disease was a major concern for this patient. This is a rare disease that is characterized by the absence of mesenteric neurons in the distal colon. ^{1,2,3,4.5,6,8,9} Due to the absence of innervation, this portion of the colon remains in a stare of contraction. The contracted bowel produces a physical obstruction to the passage of fecal material and the preceding portion of the colon becomes dilated.^l,2 Symptoms are recognized to be the delay in the passage of the meconium to more than 48 hours, the in- ability to pass stool without the aid of enemas/suppositories, abdominal distension, and inadequate nutrition. ^{1, 2, 3, 4, 5, 6, 7, 8, 9,10, 11,12} The symptoms are almost always present from birth.^8,9,10,11

Diagnosis is achieved through barium enema study that demonstrates enlarged segment of the colon followed by a constricted segment. Biopsy confirms the absence of nerve cells in that segment.^1,2,3,4,6,7 This defect requires surgical correction. ^1.2

Intussusception occurs when a part of the bowel folds into another part of the bowel and is pulled along by the peristaltic contractions. In children 3 months to 3 years intestinal obstructions are most commonly caused by an intussusception. Vomiting and episodes of colicky pain characterise this condition. An intussusception can cause a physical obstruction to waste material passing through the gastrointestinal tract. Additionally there may be blood or mucous present in the stool. Most cases present before the patient reaches their first birthday with the highest incidence between five and nine months of age. ^{5,6,7,8,9,10,11} Diagnosis of this condition is usually achieved by a contrast study although it may be demonstrated on plain film radiography. ^5,6,7

Meconium ileus is a condition that is rarely associated with patients who do not have cystic fibrosis. The inspissated meconium becomes lodged in the intestines causing an obstruction. Failure to pass meconium along with vomiting and distension are clinical signs that the infant is being affected by this condition. This condition can be demonstrated by utilizing contrast media to reveal distal ileum containing the inspissated meconium preceded by bowel dilation. Correction of the obstruction can be achieved through enemas such as Gastrografin or Hypaque or surgical removal. ^5,6,7

The rectum is essentially an organ designed to sense the volume of waste material it contains. When it becomes full, the pressure signals the intrinsic nervous system to begin evacuation. The stool is then moved through the anal canal by peristaltic contractions. ^5,6,7,12,13 A disruption in the parasympathetic innervation to the colon could result in decreased sensation and impair the bowel's ability to evacuate its contents.¹ Parasympathetic innervation is achieved through the brain stem via the vagus nerve and the S2 and S3 sacra! roots. An upper cervical subluxation may put pressure on the brain stem and alter the function of the vagus nerve.^14,15

  CASE HISTORY

A three-month-old infant is presented in the office by her parent with ongoing complaints of irregular bowel habits since birth. The infant is exclusively breastfed. The patient's history includes non-complicated gestation, birth and the passage of meconium within two days. Neither the infant nor the mother were taking any medications.

A side posture upper cervical setup with the Laney instrument and following a line of drive (ASL) formulated from the palpation findings.

 The infant breastfeeds every three hours ingesting all estimated three to four ounces at each feeding. The parent relates that the infant doesn't like to lie down preferring to be held and that the patient sleeps semi-upright in a baby seat. Additionally the parent relates that the infant is fussy at night after being fed, possibly due to discomfort. The parent reports that the infant may go for more than one week at a time without a bowel movement. The parent was advised by her paediatrician to administer a suppository to stimulate defecation if none had occurred in the preceding 7 to 10 days. The suppositories are successful and bowel movements occur as a large volume of loose stool with no complications.

The parent took the infant to a children's hospital for evaluation. A barium enema study was performed and proved normal with mobile cecum effectively ruling out Hirschsprung's disease. An x-ray study performed previously also revealed normal, findings. Of note was the discovery of a broken left clavicle in this x-ray study indicating significant birth trauma.

 INTERVENTION AND OUTCOME

Gentle digital palpation of the cervical spine revealed left paravertebral muscle spasm with articular pillar tender- ness at C2 on the left. Atlas was palpated to be laterally displaced to the left. Dorso-lumbar palpation revealed severe erector muscle spasm on the right. Postural observations revealed left head tilt. Treatments were initiated with an initial frequency of twice weekly for two weeks, then once weekly for two weeks, followed by once biweekly for one month.

Chiropractic upper cervical adjustments were performed using the Laney instrument and following a line of drive (ASL) formulated from the palpation findings. The infant was held in a side lying position on the adjusting table by the parent. After the third adjustment the parent reported that the infant was doing better and that she moved her bowels before leaving the office. The parent remarked that this was the first time her daughter had moved her bowels without the aid of suppositories. By the fifth visit the parent related that the infant was able to sleep better and was able to lie down on her back without discomfort. Additionally, it was noted that the patient's posture had improved and she no longer demonstrated left head tilt. Her bowel movements had increased to one or more movements daily. Palpatory findings revealed mild right lumbar erector spinae muscle spasm, which was considerably reduced from her initial examination. The parent reported at the sixth visit that the infant was doing much better and there were no complaints of irregular bowel habits. The parent did note that the movements had slowed down slightly since she began to feed cereal to her daughter. The patient was released from active care and the parent was instructed to make return appointments as needed. Follow up calls were made three times in the next year and the parent reported each time that the child no longer had difficulty evacuating and was otherwise healthy.

 DISCUSSION

When dealing with the apparent inability of an infant to voluntarily defecate, multiple factors must be evaluated. It is considered normal for an infant to have a bowel movement after each feeding. The pattern does vary with each individual and a breast-fed infant may have less frequent stools than a formula fed infant.^5,6,7 However it is not normal for bowel movement to require the aid of suppositories. Since the infant is exclusively breast-fed and the mother and infant are not on any medication it would stand to reason that the cause of the irregular bowel movements would not lie in the dietary factors. The fact that upon administration of the suppository, the bowel movements occurred as a large loose stool could be suggestive of Hirschsprung's disease.^12,13 The passage of the meconium within two days and the barium study effectively rule out this disease as a consideration. Additionally, an obstruction would no longer be a consideration because bowel movements were achieved. The barium study also demonstrated that the cecum was mobile and there was no evidence of meconium ileus or intussusception.

Considering that the birthing process was traumatic enough to cause the left clavicle to fracture, it is possible that a subluxation of the upper cervical vertebrae had occurred. This malpositioning of the vertebrae could place significant stress on the brain stem and subsequently the parasympathetic nervous system. The disturbance in parasympathetic innervation may decrease motility, sensation and impair the process of defecation. ^1,2,16,17 Adjustment of the upper cervical spine may improve the biomechanics and positioning of the vertebrae involved. With the stress removed, the nervous system input to the gastrointestinal tract may be restored.

 CONCLUSION

What is most remarkable about this case is that the infant's condition significantly improved after beginning chiropractic care. The parent noted that the child responded very quickly to the adjustments and the results in improved bowel function were seen within the first three adjustments. The patient was adjusted in the upper cervical region a total of six times over a five-week period. Chiropractic care may have had favorable effects on the function of the infant's lower intestinal tract. These effects would include increasing her ability to excrete waste material at more regular intervals without the aid of suppositories. The parent relates that her daughter's bowel habits have improved and remain normal. No other measures to improve this condition were sought.

 REFERENCES

1. Bertomeu A, et al: Chronic diarrhea with normal stool , and colonic examinations: Organic or Functional? J Clin GastrentestinaI1991;13:531.
2. Isselbache K, et al. Harrison's Principles of Internal Medicine. NY: Mc Graw-Hi!I, 1994.
3. Liebman WM. Recurrent abdominal pain in children: A retrospective survey of 119 patients. Clin Pediatrics 1978; 17:149.
4. Hay W, et al. Current Pediatric Diagnosis and Treatment 12th edition. East Norwalk, CT: Appleton & Lange, 1995; 630-632.
5. Silverberg M. Constipation in infants and children. Pract Gastroenterol1987; 11 :43.
6. Mc Millan J, et al. Oski's Pediatrics -Principles and Practice, Third edition. Philadelphia,

      PA: Lippincott Williams & Wilkins,1999; 313, 1245, 1636-1639, 1652-1653

7. Loening- Baucke V. Chronic constipation in children. Gastro- enterology 1993; 105:1557
8. Seth R, Heyman MB. Management of constipation and encopresis in infants and children.   Gastrenterol Clin North Am 1994; 23(4):621-636.
9. Schwartz M. W., et al. The 5-Minute Pediattic Consult. Baltimore,MD:LippincottWilliams & Wilkins, 1997; 2-3, 14-15, 266, 444-445, 838-839.
10. Ein SH, et al. Intussusception due to lymphoma. J Pediatr Surg 1986;21:768-788.
11. Park RW, Grand RJ. Gastrointestinal manifestations of cystic fibrosis: a review. Gastroenterology 1981; 81: 1143-1161.
12. Di Lorenzo C, Flores AF. Use of colonic manometry to differentiate causes of intractable constipation in children. J Pediatr 1992; 120:690-695.
13. Berkowitz C. Pediatrics; A Primary Care Approach. Philadel- phia. PA: W.B.Saunders Co, 1996; 347.349-352.
14. Lawrence D. Fundamentals of Chiropractic Diagnosis and Management. Baltimore, MD: Williams & Wilkins, 1991.
15. Anrig C, Plaugher G. Chiropractic Pediatrics. Baltimore, MD; Williams & Wilkins, 1998; 552.

16. Barry RJ, Eggenton J. Electrical activity of the intestine- + ..

 Julie Mayer Hunt, D.C., D.I.C.C.P. Private practice. 1400 Court Street. Clearwater; Florida 33756.

 JOURNAL OF CLINICAL CHIROPRACTIC PEDIATRICS  Volume 5, No. 1 2000