A story about a small feisty warrior.

Abstract

A five month old child with biliary atresia and cholestasis was treated with acupuncture, ursodeoxycholic acid, naturopathy and Chinese herbal medicine with a positive outcome.

Keywords: biliary atresia, cholestasis, paediatric, UDCA, acupuncture.

Kip

I first met Kipano on 1 April 2004. He brought with him his devoted mum Kathryn and a diagnosis of 'extra hepatic biliary atresia (1) with significant cholestasis (2) and hepatic fibrosis (3)'. He was a tiny five and a half month old and appeared oblivious to the averted eyes and obvious discomfort of the other patients in our waiting room as they struggled to compose themselves in the face of his brilliant khaki coloured skin and burnt orange eyes.

At Sydney's Westmead Children's hospital, a 'Kasai' (the surgical procedure of choice in the treatment of biliary atresia) when Kipano was all of 7 weeks old had been successful, meaning that a loop of intestine had been refashioned to form the bile duct. This meant that his body now had the necessary 'bits' to start functioning normally. His gall bladder had also been removed. He was not yet on the waiting list for a liver transplant but was being closely monitored.

Fever, pale stools and increasing bilirubin levels had seen Kip admitted to hospital just 2 weeks prior to our meeting. He had developed cholangitis (4), a common problem after a Kasai. His parents developed some concerns when they subsequently discovered that even children's Panadol could cause the child harm as it is metabolised via the liver. Once Kip was released from hospital, Kathryn chose to seek out professional holistic treatment for her son.

Kipano presented at our first consultation with severe jaundice. He suffered frequent reflux and vomiting, both just after his bottle-feed and at times up to three hours later. Frequently grumpy, grizzly and irritable, worse in the heat, Kip suffered unsettled sleep and night sweats at times. He had significant abdominal distension. His stool colour ranged from butter yellow to clay coloured. His urine was dark, but he was also on a vitamin supplement that clearly influenced the urine colour. Bilirubin levels were between 159-122 umol/L above normal (1-15 umol/L). He also sported a rather prominent umbilical hernia that had appeared after surgery. Kip's weight and height was significantly below average, but with good strong legs he was learning to stand. A strong spirit was revealed by his sparkly eye contact. His finger capillary interestingly, was a narrow dark purplish red and did not reach the qi gate (5,6). I find pulse and tongue difficult to use as diagnostic tools in children his age--they move too much and will not open their mouth when asked.

Kathryn gave me the run-down of his medications: Bactrim (Trimethoprim and Sulfamethoxazole: an antibacterial combination drug that treats bacterial infections) three times a week, Losec (Omeprazole, a proton-pump inhibitor for acid-related diseases) daily, Pentavite (multivitamin supplement) twice daily and vitamin K twice daily. Then Kath mentioned 'bear bile' and my gut immediately contracted as I have actively campaigned against the sadistic and amoral bear bile trade. It soon came out that in Kath's desperation during Kip's recent hospitalisation, she had done some research and subsequently approached Kip's paediatrician asking if they might use bear bile. The professor sensibly sourced 'Ursofalk' (ursodeoxycholic acid/ UDCA) which is synthetically derived a find imported from Germany. In Australia this is available, but only on authority prescription. So there was relief all round, and particularly so since Kip's bilirubin levels had already started to drop in the 10 days since starting his UDCA.

The day before his first acupuncture treatment, Kip had begun a Chinese herbal formula of granule extracts. The base formula contained herbs to clear heat and drain damp from and benefit both the Liver and Gall Bladder. Ingredients were also added to cool and invigorate blood, resolve blood stasis, dissolve food, transform accumulation and regulate and move the qi. Kip had obediently begun to guzzle his herbs in his milk twice daily.

Kip then began an intense course of acupuncture. Three times a week he compliantly received a base prescription of Yanglingquan GB-34, Taichong LIV-3, Zusanli ST-36 or Fenglong ST-40, and Yinlingquan SP-9. Kip sometimes anticipates what points I am about to use and trustingly offers a hand or limb in readiness. If vomiting or reflux increase, we add Neiguan P-6 and Zhongwan REN-12. When teething starts to bother him we add Hegu L.I.-4. No fancy or complicated treatments, but simple treatments just repeated over and over again. In the beginning we made appointments, but the day I saw Kath standing in the waiting room holding Kip, dead on time and wearing what I thought were her pyjamas, we dropped the appointment times. Now they just arrive and wait until I am free. As his entire treatment takes a maximum of ten minutes it is easy to squeeze him in.

During the following months Kip went through various phases in response to his treatment and some of the highlights follow.

At his second acupuncture session, Kip's finger capillary was already dramatically changed, now being a paler red and shorter, just past the 'wind gate'. For a few weeks Kip would suddenly become intensely tired during his acupuncture treatment and he would have to go home to nap immediately or he would sleep very deeply that night. Kip also began to sigh occasionally upon needle insertion, more often when I needled Yanglingquan GB-34. It was this same week that the colour of his skin noticeably began to normalise. By the end of April his sleep and moods had improved and his night sweats had mostly subsided. One day our quiet, cute Kip crawled after a child much bigger than himself and after cornering him stole the child's food. When I heard this story I realized that Kip would be OK.

By the end of May, his colour was looking good and his appetite had become ravenous. He had started on solids but would only eat them if allowed to feed himself. We discovered through a process of trial and error that Kip rejected foods that were still cold from the refrigerator and he also rejected cow's milk yoghurt, preferring soy milk yoghurt. From then on Kip's diet exclusively consisted of warm or room temperature foods. I stood corrected. For whatever reason, in the confusion of his health crisis I had not previously spelt out to Kath some really basic Chinese medicine information about the need for warm foods and being cautious with dairy products.

Upon his return from a holiday break, Kip began to yell and protest during his acupuncture. Momentarily perturbed, I quickly remembered the words of my teacher Dr. Dongsen Li. He described how as babies develop strong qi, they begin to yell and the louder they yell the stronger their qi. We pressed on with thrice weekly acupuncture, daily UDCA and ceaseless herbs.

When he started his herbs and acupuncture treatment, Kipano's bilirubin levels were between 159-122 above normal. In early June his monthly test results confirmed what we already suspected. His bilirubin levels only needed to drop by 15 to be within normal range and his blood clotting range was acceptable. These results meant he was not, for the time being, considered to be a potential candidate for a liver transplant. Those of us with gall bladders celebrated with chocolate, then returned to work.

Encouraged by his dramatic improvement since starting Chinese medicine treatment, Kip was taken to naturopath Elizabeth d'Avigdor in mid-June. Ms d'Avigdor put him on another very simple programme to enhance his digestive process. With this in mind, Kip began a regime of pre7- and pro- biotic supplements to support a diet that excluded foods most commonly found to be allergenic or not well tolerated. The digestive approach is vital to ensure that the immune system is not compromised in any way, given Kipano's particular vulnerability to the risk of infection via cholangitis. Shortly after adopting this regime, Kipano was putting on weight and showed no signs of digestive difficulties. Kathryn was advised to continue with a supportive child's multivitamin and mineral formula with pre--and pro--biotics, as a maintenance programme. Around this time it was decided to take Kip off Bactrim. His parents are vigilant for signs of early stage infections and so far there have been none.

Bilirubin levels were 16 in his early August '04 tests, the normal range being 1-15 umol/L. At this point Kip was taken off the UDCA.

Kip now began to eat and eat, indeed he sometimes eats more than his parents. By mid-August he was taller and heavier, and vitamin test results were all within normal range. He is still small for his age but is catching up faster than before. For the time being he is not taking vitamin K supplements; his body is being encouraged to function independently. Kip has begun to do cute baby things such as wrinkling his nose while smiling and he can now wave (almost appropriately). These small steps are ones that we take for granted in normal circumstances, but for Kip it was excellent progress. This was reinforced to us by reports from the parents of the other five babies diagnosed with and being treated for biliary atresia at Westmead along with Kip. Of the five, three have undergone liver transplants already, and the other two are currently on the waiting list for a transplant.

One of the reasons I felt Kip's story should be documented was because of how dramatically his health improved with such simple interventions. His Chinese herbal formula is not complex. His acupuncture was so predictable that even Kip, as a six month old baby, knew what was coming at times and his dietary guidelines basic. And yet these few, almost minimalist, procedures have completely transformed this child's life and that of his family. Now, five months since starting these treatments, Kipano's complexion is clear and milky-white with no signs of jaundice. In the waiting room he charms all those who, in the beginning, cringed and did not know where to look. I know a lot of practitioners are fearful of treating children and I hope that this story gives you the confidence to do so. It is probably not as difficult as you think and the rewards are so great.

Kipano's story also highlighted for me the great importance of early intervention. Childhood is a time of rapid growth and if health (or other) problems impede progress into the next developmental stage, it can be very difficult for a child to catch up. quite instrumental in pulling Kip out of his health crisis in March (see diagram). Combined with his other complementary medical interventions, Kip is now well on his way to recovery.

[FIGURE 1 OMITTED]

Appendix

The illegal international trade in bear gall and bear bile continues. Bear bile products are used to treat heat, fever, haemorrhoids, conjunctivitis and liver disease. 'Luxury' products said to contain bear bile, such as wines, shampoo, tonics and eye drops, are marketed to create and feed a growing demand.

In bear bile farms in China, Asiatic black bears are incarcerated in tiny wire cages, with rusting metal catheters implanted in their abdomens through which bile is extracted. The catheterisation procedure is said to "commonly result in ulcerations and infections. Bile drips from this wound causing immense agony. Bears subject to this kind of 'farming' endure the most appalling levels of cruelty and neglect". These bears fall under the protection of CITES (Convention on International Trade in Endangered Species).

As well as synthetic UDCA, Chinese herbalists know that there are many other bitter cold herbs that may be effectively used as alternatives to these products. WSPA (World Society for the Protection of Animals) will be releasing a report in 2005 listing herbal alternatives to bear bile. Environment Australia produce a very helpful booklet called 'Wildlife conservation and complementary medicines'. This booklet contains lists of alternative herbal substitutes to wildlife and endangered species: <www.biodiversity.environment.gov.au/wildlife>

Practitioners and consumers are urged to stop using products that contain, or claim to contain bear bile or gall. TCM practitioners are encouraged to become involved in WSPA's campaign against this trade. Their website address is <www.wspa-international.org>

Notes

(1.) Biliary atresia occurs when there is obstruction of the biliary tree due to progressive sclerosis of the common bile duct. In most cases biliary atresia develops several weeks after birth, probably after inflammation and scarring of the extrahepatic (and sometimes intrahepatic) bile ducts. It is rarely found in stillborns or in newborns at birth. The cause of the inflammatory response is unknown; rarely, a specific viral organism has been implicated. Symptoms represent a continuum of disorders rather than distinct entities. They include cholestatic jaundice with mixed hyperbilirubinaemia, dark urine, acholic stools and hepatomegaly about 2 weeks after birth. By the age of 2 or 3 months, there may be retarded growth, irritability from pruritis and signs of portal hypertension.

(2.) The term 'cholestasis' is preferred to 'obstructive-jaundice' because a mechanical obstruction need not be present. Here, bile flow is impaired, for whatever reason. Symptoms include jaundice, dark urine, pale stools and generalised pruritis (skin itch).

(3.) Hepatic fibrosis is an accumulation of connective tissue in the liver. It is a sign of hepatic injury.

(4.) Cholangitis is characterised by fibrosing inflammation in the intrahepatic and extrahepatic bile ducts leading to narrowing of the bile ducts. If left untreated it tends to progress by obliterating the bile ducts and developing into cirrhosis. Cholangitis typically occurs after a Kasai procedure and is thought to be due to bacterial infection ascending from the bowel. It is treated with antibiotics.

(5.) The three regions (gates) refer to the capillary that is sometimes visible on the index finger of children up to around the age of three years. It is on the index finger and usually starts somewhere between Hegu L.I.-4 and Sanjian L.I.-3. If it extends past the 'wind gate' (first or proximal phalange) the disease is considered to be mild. If the capillary extends past the 'qi gate' (the second or middle phalange), the disease is severe. If it extends past the 'life gate' (the third or distal phalange) the disease is life threatening. Further diagnostic differentiation is made by assessing the colour and size of the capillary.

(6.) Kip's capillary not reaching the qi gate indicated that the disease was mild; the narrowness of the capillary indicated possible abdominal pain and/or regurgitation of milk; the colour indicated heat.

(7.) Prebiotics are indigestible carbohydrates that stimulate the growth and activity of beneficial bacteria. They are fermented in the colon and help the probiotics (e.g. acidophilis and bifidus) to flourish and adhere to the bowel wall.

References

Beers M. H. and Berkow R. 1999 The Merck Manual of Diagnosis and Therapy. Merck Research Laboratories.

Scott J. 1986 The Treatment of Children by Acupuncture. The Journal of Chinese Medicine p12, p18.

Flaws B. 1985 Turtle Tail And Other Mercies. Traditional Chinese Pediatrics. Blue Poppy Press pp13-16.

<http://newssearch.bbc.co.uk/1/low/world/asia-paci.c/702576. stm>

BBC News 2002 New warning over China bear farms. <http://newssearch.bbc.co.uk/1/low/world/asia-paci.c/2366699. stm>

BBC News 2002 China's black bears finds anctuary. <http://newssearch.bbc.co.uk/1/low/world/asia-paci.c/2580581. stm>

Bear Bile Farming Pictures. <http://www.atourhands.com/bearbile. html>

Environmental Investigation Agency 1996 Why The World Must Kill The Trade To Save The Bears, A report on the urgent need for a ban on trade in bear gall bladders and other body parts. <http://www.salvonet. com/eia/old-reports/Bears/Reports/KillTheTrade/index.html>

World Society for the Protection of Animals 2002 Inside China's torture chambers. <http://www.wspa.org.au/02news/24beartour_inside. html>

World Society for the Protection of Animals 2002 The Shocking Truth Behind Bear Bile Farming. <http://www.wspa.org.au/02news/ 24beartour_truth.html>

Animals Asia Foundation 1993 China Bear Rescue. <http://www. animalsasia.org/index.php?module=2&1g=en>

Ngaio Richards Dip. App. Sc. (Ac), M. Hlth. Sc. (TCM) runs two busy practices in Sydney Australia in which Gynaecology and Obstetric acupuncture and herbal medicine feature strongly. Graduating in 1992 from the Acupuncture College of Australia, in 2002 she received a Master of Health Science in TCM from the University of Technology, Sydney. She practised for five years in a Paediatric acupuncture clinic in Sydney, prior to the current clinic arrangement where she continues to also needle many little ones.