Alcantara J, Ohm J, Kunz D.
International Chiropractic Pediatric Association,
Media, PA, USA.
BACKGROUND: With continued popularity of complementary and alternative medicine (CAM) therapies for children, their safety and effectiveness are of high concern for both CAM and conventional therapy providers. Chiropractic is the most popular form of practitioner-based CAM therapies for children.
OBJECTIVE: The objective of this study was to describe the practice of pediatric chiropractic, including its safety and effectiveness. DESIGN: This study used a cross-sectional survey.
SETTING: A practice-based research network was used for this study.
PATIENTS/PARTICIPANTS: Participants were chiropractors and parents of pediatric patients (aged < or =18 years) attending chiropractic visits ranging from one to 12 visits.
INTERVENTION: This is a survey study. No interventions were rendered in the completion of this study.
MAIN OUTCOME MEASURES: Demographics, clinical presentations, treatment-associated aggravations, complications and improvements.
RESULTS: The indicated primary reason for chiropractic care of children was “wellness care.” With respect to condition-based presentations, musculoskeletal conditions were the most common, in addition to nonmusculoskeletal conditions of childhood. The most common techniques used were diversified technique, Gonstead technique, Thompson technique, and activator methods. Treatment-associated complications were not indicated by the chiropractic and parent responders. 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.
CONCLUSIONS: Both sets of responders indicated a high rate of improvement with respect to the children’s presenting complaints, in addition to salutary effects unrelated to the children’s initial clinical presentations.
From the FULL TEXT Article:
Contemporaneous with the ever-expanding use of complementary and alternative medicine (CAM) by adults is the burgeoning interest in CAM therapies for children. Eisenberg et al  determined that CAM utilization by adults increased from 34% in the early 1990s to 42% in the late 1990s. During this same time period, CAM pediatric utilization increased from 11% to 20%.  Of the array of CAM therapies available to children, chiropractic is the most popular practitioner-based CAM therapy [3, 4] and is referred to as pediatric chiropractic.  Pediatric visits for CAM treatment are for a wide range of disorders, including pain, respiratory and gastrointestinal tract problems, ear infections, enuresis, and hyperactivity, among others. [4, 6] A study by Lee et al  characterizing the chiropractic care of children extrapolated that 30 million pediatric patient visits were made to chiropractors in 1997 at a cost of approximately $1 billion, with parents paying some $510 million out of pocket.
Given its continuing popularity, pediatric chiropractic therefore represents a substantial and significant aspect of CAM therapy for children. In a discussion of the evidence for safety and effectiveness of manual therapy for children, Huijbregts  pointed out that there is no clear evidence of harm to date. Considering the diversity of approaches in pediatric spinal manipulative therapy (SMT), research on outcome and harm for one treatment approach cannot and should not be applied to all. The safety of chiropractic care in general and the treatment of children in particular continue to generate controversy and debate. [8, 9] The results of this study, and a careful reading of the literature to date, suggest that in general, SMT for children is extremely safe.
The area of greatest controversy regarding the safety of chiropractic care has been that of SMT of the cervical spine. DiFabio  examined 177 cases involving SMT of the cervical spine as reported in 116 articles published between 1925 and 1997. Although the subjects’ age ranged from four months to 87 years, the majority of the cases involved adult patients (average age 39.6 years), and those involving children (ie, aged <18 years) were not well described. The most frequently reported injuries involved arterial dissection or spasm, lesions of the brain stem, and Wallenberg syndrome. The “other” category included visual deficits, hearing loss, balance deficits, and phrenic nerve injury. Ernst  described two cases associated with an adverse reaction to SMT. One case involved an infant with congenital torticollis treated with chiropractic spinal manipulation.  Within a few hours of receiving care, the child suffered from respiratory distress, quadriplegia, and seizures. A holocord astrocytoma with excessive acute necrosis was found and resected. The second case involved a three-month-old girl treated by a German physiotherapist with forced rotation and retraction of the head.  As a result of the care rendered, both vertebral arteries dissected, causing ischemia of the caudal brain stem with subarachnoid hemorrhage. The diagnosis was confirmed with magnetic resonance imaging, and the child died.
Second only to chiropractors in frequency, osteopaths often perform SMT on patients as part of their treatment approach. To address the issue of safety of pediatric osteopathic SMT (OSMT), Hayes and Bezilla  performed a retrospective review of medical records of pediatric patients receiving OSMT. Treatment-associated aggravations and complication as previously defined were documented. Of 502 records reviewed, 346 files met their inclusion criteria (ie, patient received two or more office visits) for analysis. No OSMT-related complications were documented. Nine percent (n=31) of 346 patients reported an OMT-associated aggravation; specific reports included worsening symptoms (n=7), behavior problems (n=5), irritability (n=5), pain (n-4), soreness (n=4), headache (n=2), dizziness (n=1), flulike symptoms (n=1), treatment reaction (n=1), and tiredness (n=1). Based on their findings, Hayes and Bezilla  concluded that OSMT appears to be a safe treatment modality for the pediatric population.
Vohra et al  performed a systematic review of the literature documenting adverse events associated with pediatric SMT. Using eight databases and spanning a timeline of 104 years of scientific publications, Vohra et al  found only 14 instances of adverse events associated with pediatric SMT. The adverse events include irritability (n=1), loss of consciousness (n=1), midback soreness (n=1), acute lumbar pain (n=1), headache and stiff neck (n=1), severe neurological deficits (n=5), anterior dislocation of the atlas and fracture of the odontoid axis at C2 (n=1), atlas dislocation (n=1), and death (n=2). Ten of the 14 cases were attributed to chiropractic. Controversy remains around the interpretation of the findings of this review. Five of the 10 cases involved adverse events that were minor, self-limiting, and did not require hospitalization or medical attention. In the cases involving severe neurological loss or spine fracture or death, the patients had a preexisting medical condition and/or had a history of neurological trauma, which make it difficult to clearly attribute the adverse event to the SMT
Miller and Benfield  recently published a three-year retrospective analysis of adverse events associated with pediatric SMT at the Anglo European College of Chiropractic. Based on 697 children attending 5,242 patient visits, the authors reported that minor adverse reaction is likely to occur at the rate of approximately one per 100 children, or one reaction reported for every 749 treatments in their patient population. Two potential concerns regarding this review are the fact that an adverse event was based solely on parental report of excessive crying, and that the study was performed at a chiropractic teaching clinic with SMT rendered by chiropractic students. Questions remain regarding whether excessive crying on parent report is an adequate way to evaluate adverse effects, and also regarding whether the outcomes of care rendered by students can be generalized to the overall practice of pediatric chiropractic. Our survey of chiropractors reported that 0.51% of the patient population, or one in 1,812 patient visits resulted in a minor adverse events. The results from our parent survey indicate 0.83% of the patient population, or one in 867 clinical encounters, resulted in a minor adverse event. All reported aggravations (from chiropractor and parent survey) were minor, self-limiting, and did not require hospitalization or medical attention. More importantly, the complaints were addressed by the treating chiropractor in subsequent visits and did not dissuade the parent from continuing care for their child.
Based on the National Cancer Institute’s  the reported adverse events reported herein were mild (ie, minor, no specific medical intervention, asymptomatic laboratory findings only, radiographic findings only, marginal clinical relevance) in nature. Minor side effects have been reported in 30% to 55% of adults receiving chiropractic SMT, [20-23] whereas in this study, less than 1% of the pediatric population experienced minor adverse events based on chiropractor and parent responders. Several factors may contribute to the low prevalence of adverse events, including possible underreporting of adverse events, limitations in our study design, and selection bias in patients choosing to participate. It is also possible that chiropractors and other clinicians performing SMT in children, aware as they are of the unique biomechanical features of the pediatric spine,  are more cautious in their approach than some may be in their approach to SMT in adults. The forces applied during SMT in children are much less than those applied to adults; contact points are altered, patient and chiropractor positions are modified, and low force techniques are compared to high-velocity techniques may be applied less frequently. Also, the malleable and hypermobile nature of the pediatric spine may confer a greater amount of adaptability in the pediatric spine as compared with the typical response seen in adults.
Chiropractic and Wellness Care
According to Jean and Cyr,  pediatric patients use CAM approaches for a wide variety of health issues, but principally for chronic conditions involving musculoskeletal, psychological, and infectious problems. Spigelblatt et al  found that the three most common presenting conditions/reasons for children seeking chiropractic care were respiratory; ear, nose, and throat problems; and musculoskeletal conditions. Nyiendo and Olsen  examined the characteristics of 217 children attending care at a chiropractic college teaching clinic and found that 42% suffered from musculoskeletal complaints, 20% from nonmusculoskeletal complaints, and 33% attended the clinic for general physical examination. Verhoef and Papadopoulos  examined the treatment of patients aged less than 18 years by Canadian chiropractors and found that musculoskeletal conditions were the most common presenting complaints, followed by asthma and headaches. The findings of our study support the popularity of musculoskeletal conditions as a presenting complaint in the pediatric population insofar as when there is a specific condition indicated.
An important finding of our study, however, is the high frequency with which children were brought to the chiropractor specifically for wellness care. As pointed out by Hawk, [27, 28] chiropractic has at its core a vitalistic and holistic theoretical framework and approach to patient care, which incorporates a number of prevention and health promotion strategies, [27-30] particularly in the training of chiropractors. With the formalization of the model course for public health education in chiropractic colleges  and inclusion of public health preventive measures within the scope of chiropractic practice,  chiropractic is actively moving toward becoming a “wellness profession.” [27-31] The findings of our study demonstrate that this evolution is being manifested in the clinical practice of pediatric chiropractic. The frequency of wellness care as a motivation for chiropractic care of children was first documented by Rubin.  In examining the presenting complaints of new patients to his pediatric clinic, he found that wellness care was a common reason for presentation, along with spinal, respiratory, stomach, and sleep problems. Some studies also show a similar phenomenon in adults; in an international survey of sacro-occipital technique in adult patients, Blum et al  found that 42% of 1,316 patients presented for care either for wellness, prevention, or to reduce their risk of illness or injury. Kemper,  in addressing the issue of effectiveness of CAM therapies for children, admonished that to answer the question of whether or not CAM therapies work, one of the essential components must be that the families’ goals and expectations of treatment be elicited systematically. The role of wellness care in a family’s choice to pursue chiropractic care should be part of this evaluation