Safety and Effectiveness of Pediatric Chiropractic
By Gina Shaw
Look around your child’s or grandchild’s school, a playground, a carnival or an amusement park. For every 100 children you see, at least three of them have probably visited a doctor of chiropractic at least once. According to a report from the U.S. Centers for Disease Control and Prevention, approximately 3 percent of children have been treated with chiropractic or osteopathic manipulation.
The numbers are rising. In 2000, a survey found that there were about 30 million pediatric visits to chiropractors1; by 2009, that figure had more than doubled, to 68 million.2 The National Board of Chiropractic Examiners’ most recent practice analysis, issued in 2010, found that about 17 percent of chiropractic patients were under age 18 — approximately 7.7 percent aged five years or younger and some 9.4 percent between ages six and 17.
With chiropractic care involving children becoming so commonplace, it’s important to understand the evidence regarding its safety and effectiveness. Several reviews of the literature in recent years have examined the safety of pediatric chiropractic:
A 2011 review by Matthew Doyle found a rate of .53 percent to 1 percent mild adverse events for pediatric chiropractic manipulative therapy.3
A 2009 survey study by Alcantara et al. surveyed both chiropractors and parents of pediatric patients in a practice-based chiropractic research network. Chiropractor responders indicated three adverse events per 5,438 office visits from the treatment of 577 children. The parent responders indicated two adverse events from 1,735 office visits involving the care of 239 children.4 (This study has been criticized for some methodological weaknesses, however.)
A 2007 analysis by Vohra et al., involving two randomized trials and 11 observational reports, found nine serious adverse events and five mild to moderate adverse events, as well as 20 cases of delayed diagnosis for other conditions. 5
"The Vohra study looked at all the peer-reviewed literature over 110 years and involved not just chiropractic practitioners, but anyone doing spinal manipulation,” says DC and Diplomate in Clinical Chiropractic Pediatrics (DICCP) Elise Hewitt, a Portland, Ore. pediatric chiropractor who serves as president of ACA’s Council on Chiropractic Pediatrics. “That’s nine serious adverse events in 110 years. They were serious, absolutely, and we should not downplay them, but those numbers are very small considering how many millions of pediatric chiropractic visits there were over that same time period.”
Looking beyond just the peer-reviewed literature, Dr. Hewitt says, there’s another strong indicator of the safety of chiropractic in general and pediatric chiropractic in particular: insurance rates. “Chiropractors have the lowest malpractice rates of all primary health care providers in the country, and those rates are based on risk. Actuaries aren’t going to give us lower rates without good reason. And as a pediatric chiropractor, my rates are exactly the same as my colleagues who treat adults.”
Dr. Hewitt also points to the issue of relative risk. One of the most common reasons parents bring their children to the chiropractor is formanagement of chronic ear infections. The other common treatment for ear infections, of course, is antibiotics. In a 2009 review of pediatric adverse drug events in the outpatient setting, Bourgeois et al. found that an average of more than 585,000 pediatric adverse drug events requiring medical attention occur each year; by far the most common culprits in these cases, at 27.5 percent, were antimicrobial agents.
The key to safety in pediatric chiropractic is education, says Jennifer Brocker, DC, DICCP, who practices with Dr. Hewitt. “It’s a completely different process when you work with kids, and you have to know what you’re doing in order to treat them appropriately. You need to know the proper techniques,contacts and depth. The contacts need to be smaller and the thrust more shallow with less force. Pediatric chiropractic is extremely safe if you know what you’re doing, but less so if you don’t.”
“Children have the same joints that we do, but they’re not fully formed yet,” adds Emily Watters, DC, who practices in Portland’s Whole Mama Whole Child chiropractic and craniosacral clinic. “Their joints are still more cartilaginous than trulybony, so the adjustments have to be a little bit faster but with less force. This is due to the increased flexibility within the joint and the smaller surface area you are targeting. With kids, another option in certain cases is to mobilize joints rather than manipulate them.
“Pediatric chiropractic also differs dramatically from treating adults when it comes to the nature of the complaints. Older children — middle schoolers and teens — may come in with musculoskeletal complaints that resemble those of young adults, particularly if they are involved in athletics. But younger children,toddlers and infants don’t usually arrive at the chiropractor’s office complaining that they threw their back out after lifting a really heavy Elmo doll or dancing too hard to The Fresh Beat Band.
“For young babies, the most common complaints are colic, sleepissues and nursing dysfunction,” says Dr. Hewitt. “We also frequently see plagiocephaly and torticollis.”
“Even in utero, if there was any sort of intrauterine constraint, the baby can get stuck in one position, potentially for several months,” says Dr. Watters. “Wouldn’t you be hurting if you’d been in one position for two months? From day one, they can have directional preferences, possibly due to shortened tissues during growth. The goal of treatment is to restore motion to the joints and balance the tissues to keep everything as biomechanically even as possible. Taking the tension off from day one can help allow for optimal growth and development.”
With respect to nursing dysfunction, Dr. Hewitt says, “Every baby is born with an instinctive ability to suck. If the baby can’t latch on properly, there may be a communication problem between the brain and the elements of the suck-swallow reflex. I just get the joints moving again, clearing out the irritation of the central nervous system, which opens communication pathways that let the tongue and throat muscles work properly.”
In a study published in the Journal of Manipulative and Physiological Therapeutics (JMPT) in 2009, Miller et al. reported on a clinical case series of 114 patients with “sub-optimal infantbreast-feeding” at ages 12 weeks and younger.6 The babies had all been seen by multiple practitioners, including midwives, pediatricians, lactation consultants and others, as well as the doctor of chiropractic for their feeding issues. Of the 114 babies in the case series, 89 (78 percent) were exclusively breast-fed after four chiropractic treatments.
The authors caution that there are obvious limitations to a case series vs. randomized trials, and they note, “It is not known whether this is a result of chiropractic manual treatment, the co-treatment provided along with other health care providers or the natural course of this condition.”
Nonetheless, says Dr. Hewitt, those are impressive findings. “If a baby has problems latching, there are normally very high rates of breast-feeding failure.”
Miller’s chiropractic teaching clinic in the United Kingdom has also done studies on infant colic. In another study published in JMPT, she took an innovative approach to blinding parents as to whether their baby received a chiropractic treatment or not.7 The 104 infants were randomized to one of three groups: two treatment groups and one non-treatment group. For one of the treatment groups, parents observed the infants receiving chiropractic care. For the other treatment group and the non-treatment group, parents were seated behind a wall and could not see whether their baby received the chiropractic treatment or not.
Improvements were reported via a 24-hour “crying diary” kept by the parents. “By day 10, the mean difference in the change in crying time from baseline between patients treated and not treated was 1.5 hours,” the authors wrote. “In contrast, there were no statistically significant differences in the mean change in crying time from baseline at any of the time points between the patients of parents who were and were not blinded to treatment.”
Chronic Ear Infections
For slightly older children, one of the most common reasons to visit the chiropractor is a chronic ear infection. A 2011 review of the literature by Pohlman and Holton-Brown, published in the Journal of Chiropractic Medicine, paints a conflicting picture of the evidence for its effectiveness (although the safety findings are strong).8 “From the 49 studies (17 surveys/editorials/commentaries, 15 case reports, 5 case series, 8 reviews and 4 clinical trials) found in this report, there was limited quality evidence for the use of SMT for children with otitis media,” the authors wrote. “There is currently no evidence to support or refute using SMT for OM and no evidence to suggest that SMT produces serious adverse effects for children with OM.”
How might chiropractic care improve chronic ear infections? Dr. Brocker explains the process this way, “Fluid is getting trapped in the middle ear cavity, creating a breeding ground for bacteria and viruses. Medically, you’d use an antibiotic to kill the bacteria, but that doesn’t do anything about the fluid buildup. We’re asking, why is the fluid trapped? If the muscles surrounding the Eustachian tubes are spasming, that can close down the tube’s opening and not allow the fluid to drain. Our goal is to stop those muscles from spasming.”
Quality of Life
Some claims have been made about chiropractic’s potential to have an effect on larger childhood developmental disorders and syndromes like cerebral palsy, ADHD, autism, post-stroke, Down syndrome and so on. Dr. Brocker says that no one could ever legitimately claim to “cure” a child with such conditions. “But chiropractic may make some changes that allow them to lead a more comfortable life,” she says. “You can improve their quality of life by keeping their system moving and allowing their nervous system to work the best it can, so their body can reach its fullest potential.”
“I’m not sure if there’s any evidence that shows some of these things, but I’ve had parents come back to me after I’ve adjusted their child and found some places that are restricted, and say that their behavior seemsmore calm and they’re more relaxed in their own body,” says Dr. Watters.
Pediatric Chiropractic Specialty
There are few chiropractic practices that specialize solely in children, as those of Dr. Hewitt, Dr.Brocker and Dr. Watters. “There are only about 225 DICCPs around the world, and about 175 or so spread across the 50 states in this country,” Dr. Hewitt says. “But there is more and more interest now at the student level in pediatric chiropractic practice.”
Because of the growing focus on chiropractic integration and collaboration with the medical mainstream, students are coming into the profession interested in specialization — and pediatrics is a specialty that particularly attracts the interest of young chiropractors. “There’s much more awareness among students, as well as the profession and the general public, that chiropractic can help children than there was in past years,” Dr. Hewitt says. “Every time I speak in public, my breakout sessions are always crowded because people want to learn more about pediatrics. I think in the next 20 years we will see a lot more chiropractors in this specialty.”
Launching a pediatric chiropractic practice today should be relatively easy, Dr. Hewitt believes. She hasn’t advertised in 15 years and gets patients only via referral, yet she has a two-month waiting list for new patients.
“There’s a huge need. Medical care is great for saving our lives but doesn’t do a lot for everyday quality-of-life issues that plague us. There’s a lot more anxiety and stress in kids’ lives today. As a chiropractor, the adjustments we do are great, powerful and can be life-changing,” she says. “But there are other aspects to a conservative first approach to health care that are particularly important for kids: focusing on adequate nutrition,sleep and physical activity. Parents are looking for answers besides putting their kids on more drugs. This is a great gift that we have to offer our children.”
1 Lee AC, Li DH, Kemper KJ. Chiropractic care for children. Arch Pediatr Adolesc Med. 2000;154:401–407.
2 Alcantara J, Ohm J, Kunz D. The safety and effectiveness of pediatric chiropractic. Explore (NY). 2009 Sept-Oct;5(5):290-5.).
3 Doyle M. Is chiropractic pediatric care safe? A best evidence topic. Clinical Chiropractic, v.14, no.3, 2011 Sept, p.97(9).
4 Alcantara et al.
5 Vohra et al. Adverse Events Associated With Pediatric Spinal Manipulation: A Systematic Review. Pediatrics Vol. 119 No. 1 Jan 1 2007 pp. e275 -e283.
6 Miller et al. Contribution Of Chiropractic Therapy To Resolving Suboptimal Breastfeeding: A Case Series Of 114 Infants. Journal of Manipulative and Physiological Therapeutics Volume 32, Number 8.
7 Miller et al. Efficacy Of Chiropractic Manual Therapy On Infant Colic: A Pragmatic Single-Blind, Randomized Controlled Trial. Journal of Manipulative and Physiological Therapeutics Volume 35, Number 8.
8 Pohlman KA, Holton-Brown MS. Otitis media and spinal manipulative therapy: a literature review. Journal of Chiropractic Medicine (2012) 11, 160–169.
Pediatric Best Practices
The NCMIC Foundation funded a consensus process resulting in best practice recommendations for chiropractic care of children. It is called “Best Practices Recommendations for Chiropractic Care for Infants, Children and Adolescents: Results of a Consensus Process.”1
A broad-based panel of experienced chiropractors was able to reach a high level (80 percent) of consensus regarding specific aspects of the chiropractic approach to clinical evaluation, management and manual treatment for pediatric patients, based on both scientific evidence and clinical experience. (For more on the importance of best practices documents, see September 2014 ACA News, p. 18.)
1 Hawk C, Schneider M, Ferrance RJ, Hewitt E, Van Loon M, Tanis L. Best practices recommendations for chiropractic care for infants, children, and adolescents: results of a consensus process. J Manipulative Physiol Ther. 2009 Oct;32(8):639-47. doi: 10.1016/j. jmpt.2009.08.018.
Special Populations: Pediatrics
The Council for Chiropractic Guidelines and Practice Parameters and its (CCGPP) Rapid Response Resource Center (RC3) holds the most up-to-date research on chiropractic. Its website is constantly being updated.
You will find a section called “Safety” with the latest research on the safety of chiropractic and spinal manipulation.
The below information on pediatric chiropractic research and much more is available on the RC3 website at http://clinicalcompass.org/resources/rapid-response-resource-center. (For more information on CCGPP, see the May 2014 issue of ACA News.)
A 2012 systematic reviewed stated, “studies that monitored both subjective and objective outcome measures of relevance to both patients and parents tended to report the most favorable response to SMT, especially among children with asthma.”1
Evidence is insufficient to support chiropractic care for ADHD in children.2,3
Autism spectrum disorders.
Limited literature regarding chiropractic care and autism.4 Preliminary studies suggest some benefit from chiropractic care.4
“Given the ineffectiveness of pharmaceutical agents, a trial of chiropractic care for sufferers of autism is prudent and warranted.”4 (Information obtained from abstract.)
A 2010 systematic review states that SMT is not effective for asthma, compared to sham manipulation.5 However, a 2007 review indicates that the entire clinical encounter of chiropractic care, including SMT, is beneficial to patients with asthma.6
Another 2010 systematic review states that “chiropractic care showed improvements in subjective measures and, to a lesser degree objective measures, none of which were statistically significant...some asthmatic patients may benefit from this treatment approach; however, at this time, the evidence suggests chiropractic care should be used as an adjunct, not a replacement, to traditional medical therapy.”7
BEST PRACTICES RECOMMENDATIONS
Standards for pediatric education should be developed in chiropractic college curriculum including post graduate education.8
Chiropractic treatment for infants, children and adolescents include, but are not limited to spinal manipulation, vitamins, dietary interventions, therapeutic exercise, posture correction, and physical agents. Patient preference is important.8
Adult research may not be generalizable to pediatric population.8
“Chiropractic care is a viable alternative to the care of infantile colic and congruent with evidence-based practice, particularly when one considers that medical care options are no better than placebo or have associated adverse events.”9
Cochrane database systematic review and a 2010 review found that evidence was insufficient to make conclusions about the effectiveness of SMT.3,10
Evidence is insufficient for manual therapy for spinal disorders in the pediatric population specifically. There was one RCT for TMJ disorders.11
Evidence is insufficient for SMT.3
Evidence is insufficient to support or refute SMT for OM3,12 but there is no evidence of serious adverse events from SMT for children with OM.12
Study looked at osteopathic manipulation, massage and chiropractic and found that the literature is insufficient.13
1. Gleberzon BJ, Arts J, Mei A, McManus EL. The use of spinal manipulative therapy for pediatric health conditions: a systematic review of the literature. J Can Chiropr Assoc. Jun 2012;56(2):128-141.
2. Karpouzis F, Bonello R, Pollard H. Chiropractic care for paediatric and adolescent Attention-Deficit/ Hyperactivity Disorder: A systematic review. Chiropr Osteopat. 2010;18:13.
3. Ferrance RJ, Miller J. Chiropractic diagnosis and management of non-musculoskeletal conditions in children and adolescents. Chiropr Osteopat. 2010;18:14.
4. Alcantara J, Alcantara JD, Alcantara J. A systematic review of the literature on the chiropractic care of patients with autism spectrum disorder. Explore (NY). Nov 2011;7(6):384-390.
5. Bronfort G, Haas M, Evans R, Leininger B, Triano J. Effectiveness of manual therapies: the UK evidence report. Chiropr Osteopat. 2010;18:3.
6. Hawk C, Khorsan R, Lisi AJ, Ferrance RJ, Evans MW. Chiropractic care for nonmusculoskeletal conditions: a systematic review with implications for whole systems research. J Altern Complement Med. Jun 2007;13(5):491-512.
7. Kaminskyj A, Frazier M, Johnstone K, Gleberzon BJ. Chiropractic care for patients with asthma: A systematic review of the literature. J Can Chiropr Assoc. Mar 2010;54(1):24-32.
8. Hawk C, Schneider M, Ferrance RJ, Hewitt E, Van Loon M, Tanis L. Best practices recommendations for chiropractic care for infants, children, and adolescents: results of a consensus process. J Manipulative Physiol Ther. Oct 2009;32(8):639-647.
9. Alcantara J, Alcantara JD, Alcantara J. The chiropractic care of infants with colic: a systematic review of the literature. Explore (NY). May-Jun 2011;7(3):168-174.
10. Dobson D, Lucassen PL, Miller JJ, Vlieger AM, Prescott P, Lewith G. Manipulative therapies for infantile colic. Cochrane Database Syst Rev. 2012;12:CD004796.
11. Hestbaek L, Stochkendahl MJ. The evidence base for chiropractic treatment of musculoskeletal conditions in children and adolescents: The emperor’s new suit? Chiropr Osteopat. 2010;18:15.
12. Pohlman KA, Holton-Brown MS. Otitis media and spinal manipulative therapy: a literature review. J Chiropr Med. Sep 2012;11(3):160-169.
13. Pepino VC, Ribeiro JD, Ribeiro MA, de Noronha M, Mezzacappa MA, Schivinski CI. Manual therapy for childhood respiratory disease: a systematic review. J Manipulative Physiol Ther. Jan 2013;36(1):57-65.