Infant Reflux, Cranial Manipulation, and Medication Advice
A 34-year-old mother brings her 7-week-old infant to a New Hampshire chiropractor for persistent crying and feeding difficulty. The infant was diagnosed with reflux by a pediatrician and is on prescribed famotidine. The mother reports the infant has had no fever, vomiting, or weight loss, but she is exhausted and wants to avoid more medication. The chiropractor, who has no pediatric certification, performs a gentle spinal and cranial manipulation, tells the mother that the adjustment will 'correct the nerve interference causing the reflux,' and advises her to stop the famotidine for 48 hours to see whether the adjustment works. He does not contact the pediatrician. Two days later the infant is seen in an emergency department for worsening symptoms. The mother later asks whether the chiropractor acted within New Hampshire scope and what the Board would examine. The chiropractor documented 'subluxation complex' and 'patient improved' but did not record the medication advice.
1. Was the chiropractor's advice to stop famotidine within the chiropractic scope of practice in New Hampshire? Explain the statutory and rule-based boundaries you would apply.
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Conclusion: Outside the chiropractic scope.
Reasoning:
- RSA 316-A defines chiropractic around locating and correcting subluxations or articular dysfunction and permitted adjunctive procedures. It does not authorize a chiropractor to prescribe, discontinue, or manage prescription medication.
- Telling a parent to stop famotidine for 48 hours is a medical decision, even if framed as a 'trial' to assess an adjustment. The risk is heightened in a 7-week-old and without contacting the prescribing pediatrician.
- Scope is not expanded by the patient's request or by the chiropractor's belief that the adjustment will help reflux. The Board looks at the actual conduct, not the label.
- If Board rules prohibit treating certain pediatric conditions without referral or additional training, those rules also apply. A chiropractor without pediatric certification should not hold out as managing reflux.
Exam tip: Separate 'was manipulation itself permitted' from 'was the medication advice permitted.' The second is the dispositive issue.
2. What informed-consent and documentation deficiencies appear in this record?
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Deficiencies:
- Informed consent: For a minor, the parent or guardian must consent. Consent should cover the specific procedure, risks and benefits, alternatives including continuing pediatric care, and the fact that evidence for infant manipulation for reflux is limited.
- Coordination of care: No contact with the pediatrician and no referral when symptoms worsened.
- Documentation: 'Subluxation complex' and 'patient improved' are conclusory. The record should include pre- and post-findings, the medication advice verbatim, the parent's response, any communication with the pediatrician, and a follow-up plan.
- Scope and competence: If the chiropractor lacks pediatric training, the record should show why the patient was accepted or referred.
A Board reviewer would ask whether the parent was told the adjustment was not a substitute for prescribed medication.
3. If the Board opens a complaint, what due-process steps and possible sanctions should the chiropractor expect?
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Due process:
- A complaint is filed with the Board; Board staff review it and may investigate; the chiropractor gets notice of the allegations and an opportunity to respond.
- If probable cause is found, the Board may offer a settlement or hold a hearing. The chiropractor may be represented by counsel, present evidence, and cross-examine witnesses.
- The Board must show a violation of RSA 316-A or Board rules by the applicable standard of proof.
- Sanctions can include reprimand, fine, suspension, probation, practice restrictions, additional continuing education, and conditions on pediatric practice.
- Aggravating factors: vulnerable patient, medication advice, no referral. Mitigating factors: no prior discipline, cooperation, corrective action. Appeal to the New Hampshire court follows exhaustion of the administrative process.