Cheryl Hawk, DC, PhD, Michael Schneider, DC, PhD, Randy J. Ferrance, DC, MD,
Elise Hewitt, DC, Meghan Van Loon, DC, PT, Lora Tanis, DC
Cleveland Chiropractic College,
Overland Park, KS 66210, USA.
OBJECTIVE: There has been much discussion about the role of chiropractic care in the evaluation, management, and treatment of pediatric patients. To date, no specific guidelines have been adopted that address this issue from an evidence based perspective. Previous systematic reviews of the chiropractic literature concluded that there is not yet a substantial body of high quality evidence from which to develop standard clinical guidelines. The purpose of this project was to develop recommendations on “best practices” related primarily to the evaluation and spinal manipulation aspects of pediatric chiropractic care; nonmanipulative therapies were not addressed in detail.
METHODS: Based on both clinical experience and the results of an extensive literature search, a set of seed documents was compiled to inform development of the seed statements. These were circulated electronically to the Delphi panel until consensus was reached, which was considered to be present when there was agreement by at least 80% of the panelists.
RESULTS: A multidisciplinary panel of 37 was made up primarily of doctors of chiropractic with a mean of 18 years in practice, many with post-graduate training in pediatrics. The panel represented 5 countries and 17 states; there were members of the American Chiropractic Association, the International Chiropractors Association, and the International Chiropractic Pediatric Association. The panel reached a minimum of 80% consensus on the 51 seed statements after 4 rounds.
CONCLUSIONS: A broad-based panel of experienced chiropractors was able to reach a high level (80%) 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.
From the Full-Text Article:
The National Center for Health Statistics found that manipulation by chiropractors or osteopathic physicians was the most commonly used provider-based complementary and alternative (CAM) therapy among US children under age 18 in 2007.  The most frequent complaint causing children to seek CAM care, in general, was back or neck pain (7%). Because the prevalence of low back pain (LBP) in children has been estimated to be as high as 40%, with recurrent LBP occurring in 20% of older adolescents, this is not surprising.  However, children also sought CAM care for a number of other complaints, both musculoskeletal and nonmusculoskeletal, as shown in Table 1. Approximately 12% of US children used some type of CAM therapy in 2007; about 3% used manipulation (chiropractic or osteopathic). Adolescents used CAM more than younger children, and it was more commonly used among children with more health problems and doctor visits. 
Table 1. The 10 most common conditions for which US children under age 18 sought CAM therapies in 2007
Condition Percentage Other conditions (unspecified) 8 Back/neck pain 7 Cold 7 Anxiety/stress 5 Musculoskeletal (other than back/neck) 4 ADHD/ADD 3 Sleep problems 2 Asthma 2 Sinusitis 2
CAM therapies included alternative medical systems such as acupuncture and homeopathy; nutrition and supplements; mind-body therapies such as biofeedback and meditation; and body-based therapies, including chiropractic and osteopathic manipulation, massage, and movement therapies. Percentages are rounded to nearest whole number and are based on number of children who were reported to have used any type of CAM within past year.
ADHD/ADD = attention deficit hyperactivity disorder/attention deficit disorder.
In order to best serve the health of the public, it is important that all providers maintain and follow the highest standards of patient care. This includes adherence to the principles of evidence-based practice. Evidence-based practice is “the integration of best research evidence with clinical expertise and patient values.”  However, in many cases, especially for CAM practices, the higher levels of evidence such as randomized controlled trials or large observational studies are lacking. According to Sackett, the “father” of evidence-based medicine, “evidence based medicine is not restricted to randomized trials and meta-analyses. It involves tracking down the best external evidence with which to answer our clinical questions…” [4, 5]
Chiropractic care, a “package” of conservative approaches, including manipulation, for pain management and/or promoting optimal function, has accumulated a substantial evidence base, primarily for musculoskeletal complaints.  Manipulation, performed by trained providers, has been recommended by the American College of Physicians, as having benefit for both acute and chronic LBP in adults.  Serious adverse events have been found to be rare for manipulation of the low back (estimated at 1 per 3.72 million manipulations).  Manual procedures and exercise, commonly used by chiropractors, were found in a 2008 best evidence synthesis to be beneficial for adult patients with neck pain.  A large observational study published in 2008 found no excess risk of vertebrobasilar stroke associated with chiropractic neck manipulation.  Another study found that, although minor adverse effects such as transient soreness were commonly associated with manipulation, the overwhelming majority of these resolved within 24 hours of onset and did not affect daily activities.  A 2009 systematic review of manipulation for conditions of the lower extremity found limited, but positive, evidence for adult patients with conditions of the hip, knee, and ankle, with no serious adverse events observed. 
A 2007 systematic review of chiropractic care for nonmusculoskeletal conditions concluded that “evidence from controlled studies and usual practice supports chiropractic care (the entire clinical encounter) as providing benefit to patients with asthma, cervicogenic vertigo, and infantile colic. The evidence was promising for potential benefit of manual procedures for children with otitis media and elderly patients with pneumonia.”  An important distinction should be made between the terms “chiropractic manipulation” and “chiropractic care.” The term “chiropractic care” refers to the entire clinical encounter in a chiropractic setting which may include many nonmanipulative therapies such as dietary advice, nutritional or herbal supplements, posture correction, therapeutic exercise, physiotherapeutic modalities, and behavioral counseling.
However, the large body of evidence for the effectiveness of chiropractic care for adults may not necessarily be directly applicable to infants, children, and adolescents. A 2008 systematic review on chiropractic manipulation for children’s health problems concluded that “the evidence rests primarily with clinical experience, descriptive case studies, and very few observational and experimental studies.”  The current evidence often does not make a distinction between chiropractic manipulation as a monotherapy and chiropractic care that incorporates multiple nonmanipulative therapies as a “package.”
Therefore, at this time, it is apparent that the scientific evidence base has important gaps in terms of the appropriateness of chiropractic care for infants, children, and adolescents. Safety is one of the most important issues; a recent systematic review recommended that further study is necessary to assess the safety of spinal manipulation for children.  There is not yet sufficient research evidence related specifically to children to definitively identify indications for spinal manipulation and other procedures within the chiropractic scope of practice. However, the chief factors cited as concerns in that systematic review were possible direct adverse events related to spinal manipulation and possible indirect adverse events related to delayed diagnosis or delayed medical treatment for serious conditions.
Consequently, we undertook this consensus project in order to bridge this gap in the scientific evidence, and ensure the highest quality of chiropractic care for infants, children, and adolescents. Expert consensus is a form of evidence which must be relied on when higher levels of evidence are lacking.  The purpose of the project was to make recommendations on standards of chiropractic care for children, based on the existing evidence and the consensus of a multidisciplinary group of experts on pediatrics and chiropractic. It is essential for the safety of pediatric chiropractic patients that chiropractors who care for infants, children, and adolescents have access to a document that clearly outlines the best practices for chiropractic care of infants, children, and adolescents.
There were several strengths of this consensus process. A key strength was the development and publication of the first comprehensive set of best practice guidelines regarding chiropractic care of children. The consensus statements generated from this panel of experts provide some reasonable and rational parameters to the clinical management of the infant/child/adolescent patient by chiropractic clinicians. This document was produced with the input from a wide variety of panel members; including chiropractic clinicians with extensive experience treating children, chiropractic educators and researchers, and members of the ACA, the ICA, and the ICPA. Over 80% agreement was achieved by the panel members on 51 seed statements; this is certainly an impressive level of consensus. Our panel of experts was clearly representative of the entire spectrum of the chiropractic profession, and therefore, the results can be considered quite generalizable to everyday chiropractic practice.
Another strength of this consensus process was the ability of the panel members to recognize aspects of chiropractic pediatric practice that could benefit from additional research evidence and standardization. As noted above, our panel determined that there was a need for developing standards for chiropractic college pediatric curricula and post graduate educational programs. The panel also recognized that there were only a small number of high-quality clinical studies on the topic of manipulation for a variety of health conditions found in children. They noted that “chiropractic care” was not synonymous with spinal manipulation and that chiropractors often manage infants, children, and adolescents with numerous other interventions such as vitamins, dietary interventions, therapeutic exercise and posture correction, physical agents, and other treatments. The panel suggested that much more research is needed to determine the clinical effects of these various interventions as monotherapies and “packages” of a combination of therapies. Lastly, the panel found that the vast majority of the clinical studies on manipulation and musculoskeletal pain were performed in the adult population and that the findings may not necessarily be generalizable to a pediatric population.
Finally, a key strength of this document is that the information will help to inform numerous stakeholders about a reasonable and rational approach to chiropractic care for the pediatric patient. Chiropractors can use this document as a guide to the current best practices, while patients (and their parents) can use this information to inform treatment decisions. Third-party payors and regulatory agencies may find this information useful for guiding policy decisions about chiropractic care for the pediatric population while recognizing that evidence based practice strongly considers patient-preference to be an important factor in determining the type of treatment provided. This best practice document serves as a synthesis of the best current evidence and collective expert opinion about a reasonable clinical approach to the chiropractic management of infants, children, and adolescents.
There were some limitations of this consensus process. This document was focused primarily on examination methods and manual treatment, yet chiropractic care may include many other services in addition to manipulative procedures. Chiropractic care may include the use of physiotherapy modalities, therapeutic exercise, dietary interventions, the use of vitamins and herbs, and other complementary procedures. Clearly, the use of these adjunctive and complementary procedures should be the subject of a future consensus process. One important limitation is the lack of strong evidence regarding the effective use of these procedures for children.
Another limitation was the lack of comprehensive analysis of the chiropractic educational process regarding pediatrics. A review of the chiropractic college pediatric curricula and post graduate pediatric educational programs should be performed with recommendations made by a future consensus panel. Furthermore, it would be an important step to develop a “model curriculum” for chiropractic education that will operationalize the recommendations made in the current document. Current efforts have been initiated by members of the project team to address this step.
Lastly, a limitation of any consensus process is that it represents chiefly expert opinion, which is a less convincing level of evidence than that provided by large-scale experimental studies. However, in the absence of a substantial body of literature and evidence, clinical practice must continue. Providing a reasonable approach to such clinical practice, developed through a formal consensus of expert opinion based upon best available evidence, is an important part of filling the knowledge gap. Meanwhile, it is essential that rigorous observational and experimental studies be implemented to provide a more substantial body of evidence to inform future clinical guidelines.
This consensus document describes the procedures and other features of chiropractic care which, based on the expert panel’s clinical experience and the available evidence, represent the most beneficial approach to chiropractic care for infants, children, and adolescents. This document provides a general framework for what constitutes an evidence-based and reasonable approach to the chiropractic management of infants, children, and adolescents. It should not be seen as a final product, but rather as a work-in-progress that will require refinement as new evidence emerges in the future.
Funding Sources and Potential Conflicts of Interest
This study was funded by grant #08-04-01 from the Foundation for Chiropractic Education and Research. No conflicts of interest were reported for this study.
The consensus process using a multidisciplinary panel was successful in developing a set of seed statements concerning the key issues related to chiropractic care for infants, children, and adolescents.
This document provides a general framework for what constitutes an evidence-based and reasonable approach to the chiropractic management of infants, children, and adolescents.
It should not be seen as a final product, but rather as a work-in-progress that will require refinement as new evidence emerges in the future.