Submitted by Shawn Thistle, DC, RRS Education
Article: “Best Practices for Chiropractic Care of Children: A Consensus Update”
Authors: Hawk C, Schneider MJ, Vallone S, & Hewitt EG
Publication Information: Journal of Manipulative and Physiological Therapeutics 2016; 39(3): 158-168.
Comment from Dr. Shawn Thistle:
Integrating high-quality evidence into our clinical acumen is a crucial aspect of the evolution of the chiropractic profession. However, we must also continue to respect and include expert consensus, based on years of clinical experience. Papers like this help us achieve this valuable combination! Dr. Cheryl Hawk and colleagues give us a great overview of the literature pertaining to chiropractic care for children, incorporating evidence and consensus-based advice you can apply in your practice…enjoy!
In the United States, chiropractic care is the most common type of complementary and integrative medicine used by children2 and is most often sought for the treatment of musculoskeletal conditions or infantile colic.5,9 Despite the relatively high utilization, there is little scientific evidence for the effectiveness and efficacy of chiropractic care in children. In 2009, the authors performed a consensus process to gather opinions from experts in the field on best practices in the chiropractic care of children.16 This article aimed to update these recommendations through a formal consensus process and an updated review of recent literature.
21 articles on effectiveness of chiropractic care (including spinal manipulation) in children were included, with three of those being RCTs. From these, limited support was found in high-quality studies for asthma,4, 13-15 infantile colic, 4, 12, 16-18 nocturnal enuresis,4, 19 and respiratory disease.15 Nine articles on safety were found and summarized. Serious adverse events associated with chiropractic, osteopathy, physiotherapy, or manual medical therapies were found to be rare, and when they did occur, were associated with an underlying pre-existing pathology. No deaths associated with chiropractic care were found in the literature. Consensus was reached in all but two seed statements in the first round and those were revised and reached consensus in the second round.
Consensus Statements & Clinical Application:
Consensus was reached on the following seed statements:
General Clinical Principles in the Care of Children
- Extracting relevant clinical information during the case history of a child patient requires special communication skills and experience.
- Age-appropriate communication is necessary to help a child patient engage in a clinical encounter.
- Infants and toddlers cannot communicate verbally, and therefore, the clinical encounter requires communication with a parent or legal guardian.
- Informed consent signed by the child’s parent or legal guardian is required before initiating a clinical encounter, including the initial consultation, performing an examination and diagnostic tests, and initiating a management program.
- The DC should explain all procedures clearly and simply, and answer both the parent’s and child’s questions, to ensure that they can make an informed decision about their health care choices.
- Verbal consent should be obtained from the child whenever developmentally appropriate.
- The diagnosis should be explained to the parent/guardian (and the older child) in an age-appropriate, understandable manner.
- The proposed treatment plan and any possible risks of care should be explained along with all other reasonable treatment options.
Chiropractic Management of Pediatric Patients
Clinical judgements in pediatric patients should be based on the three basic principles of evidence-based practice. These include: 1) the best available evidence, combined with 2) the clinician’s experience and 3) the patient’s preferences. Co-management with other health care providers is appropriate when:
- The child patient is not showing clinically significant improvements after an initial trial of chiropractic care.
- The parents of the child patient request such a co-management approach.
- There are significant comorbidities that are outside the scope of chiropractic practice or require medication, advanced diagnostic imaging, or laboratory studies.
- When the DC orders diagnostic imaging or laboratory studies, copies of these results should be forwarded to the child’s primary care physician for coordination of care.
- Management of many non-musculoskeletal conditions may benefit from co-management with the child’s primary care physician and/or other providers, depending on the condition.
- Immediate referral to a medical specialist should occur when the case history and examination reveal “red flags” suggestive of serious pathology. (See below for a list of red flags)
A thorough clinical history should include a systems review, developmental milestones, family history, health care history, concurrent health care, and medication use. It should also include information on health habits such as breastfeeding, diet, sleep, physical activity, and injuries. In very young children, a review of relevant prenatal events such as health of the mother and a review of the birth history is useful.
Only clinically relevant and valid examination procedures should be utilized. Vital signs should be taken in an age-appropriate manner. An age-appropriate neurodevelopmental examination should also be performed and primitive reflexes should be assessed in infants.
Diagnostic imaging is indicated in cases with a history of trauma, suspicion of serious pathology, and/or assessment of scoliosis. Radiographs should not be used in the child patient without clear clinical justification.
Signs/symptoms suggestive of emergent condition for which immediate medical referral is indicated: Infants and very young children only:
- Inability to rouse the child
- Bulging or sunken fontanelle
- Signs of dehydration and/or decreased fluid intake of 50% or greater over a period of 24 hours
- Acute weight loss exceeding 5% of body weight
- Persistent, inconsolable, high-pitched crying, or a weak cry with drowsiness
Signs/symptoms suggestive of emergent condition for which immediate medical referral is indicated: Children of any age:
- Petechial or purpuric rash
- Dyspnea, which may be accompanied by nasal flaring or significant increase in respiratory rate
- Sudden onset or persisting acute abdominal symptoms
- Persistent vomiting
- Bile-stained vomiting
- Convulsions, particularly if there is no prior history, or if associated with head trauma
- Cold, pale, white distal lower extremities and or oral cyanosis
- Fever, chest pain, altered mental status or other neurological findings in a child with Sickle Cell Disease
- Altered mental status, signs of dehydration, abdominal pain, or “fruity breath” in a child with diabetes
- Fever of 40 degrees centigrade (104° F) or higher, particularly if spiking
- Hot, swollen, tender joints, especially if the child refuses to bear weight
- Bone fracture or dislocation
- Other orthopedic emergencies such as slipped femoral epiphysis or Perthes’ disease
- Fecal blood
Signs/Symptoms suggestive of potentially serious illness for which appropriate referral and/or co-management are indicated:
- Suicidal ideation
- Slurred speech
- New onset strabismus (abnormal alignment of the eyes)
- Persistent vomiting
- Persistent diarrhea
- Recurrent fevers
- Unexplained bruising without trauma or suspicion of child abuse
- Positive neurological signs such as Babinski, Hoffman’s, absent reflexes, motor weakness
- Personality change
- Unexplained weight loss
- Parent suspects chemical substance abuse
- Scoliosis greater than 20 degrees
- Loss of developmental milestones
Considerations for Treating Children with Manual Procedures
- Patient size: Biomechanical force should be modified in proportion to the size of the child
- Structural development: Manual procedures should be modified to accommodate the developing skeleton
- Flexibility of joints: Manual procedures should take into account the greater flexibility and lesser muscle mass of children, using gentler and lighter forces
- Patient preferences: The clinician should adapt manipulation and soft tissue techniques and procedures that support the needs and comfort of the child
Pediatric Care Planning and Public Screening of Children for Health Problems
DCs should emphasize disease prevention and health promotion through counselling on physical activity, nutrition, injury prevention, and healthy lifestyle. When performing public screenings, any tests or procedures used should be based on recognized evidence showing their benefit for disease prevention and health promotion.
The original consensus study included a literature review. For this study, the literature review was updated. Search questions utilized included: 1) “What is the effectiveness of chiropractic care, including spinal manipulation, for conditions experienced by children (< 18 years of age)?”; and 2) “What are the adverse events associated with chiropractic care including spinal manipulation among children (< 18 years of age)?”
- English studies published between Jan. 1, 2009 and March 31, 2015 featuring human subjects
- Study population was < 18 years of age
- Systematic reviews, randomized controlled trials (RCTs), or cohort studies
- Evaluated effectiveness of chiropractic care and/or chiropractic manipulation
- The following types of publications were not included: commentaries, editorials, letters, non-peer-reviewed publications, surveys and other cross-sectional studies, conference abstracts, case reports/series, or pilot studies
- No treatment outcomes included
- Chiropractic care or chiropractic manipulation were not a form of treatment
Two reviewers independently screened the articles and abstracts and summaries were created for the Delphi panelists. Systematic reviews were evaluated using the AMSTAR checklist6, RCTs using the Cochrane Collaboration’s tool for assessing risk of bias in RCTs7, and cohort studies using the Newcastle-Ottawa Quality Assessment Scale.8 All articles were assessed for evidence for manual therapies using the criteria set out by Bronfort et al.9 and Clar et al.10 where “no support” indicated insufficient evidence, “limited support” indicated a small number of studies of mixed quality with positive findings, and “effective” indicated a number of studies with at least some of high quality with positive findings. Articles on adverse events were not evaluated for quality and instead their content was summarized.
Seed statements were taken verbatim from the previous consensus study5 and sent to the members of a Delphi panel of experts via e-mail. A modified RAND Corporation/University of California, Los Angeles, consensus method11 was used where panelists were asked to rate the appropriateness of each seed statement. Appropriateness was defined as the expectation that the expected health benefit is greater to the patient than any expected negative consequences, including cost concerns11. Each statement was rated on a numerical scale from 1-9 (highly inappropriate to highly appropriate). If a panelist rated a seed statement as highly inappropriate (1-3) they were required to provide a specific reason, including a citation from refereed literature wherever possible. Consensus agreement on a statement was reached when a minimum of 80% of panelists rated a statement 7, 8, or 9 (highly appropriate) and a median response score of at least 7 was obtained. Statements not reaching consensus were revised based on panelists’ comments and recirculated until consensus was reached.
Study Strengths / Weaknesses
- Using e-mail for the consensus process was economical and reduced the possibility of members of the Delphi panel influencing each other’s ratings.
- There are substantial gaps in the evidence for the effectiveness of chiropractic care for children.
- The consensus recommendations primarily dealt with examination and manual care and did not cover other services that DCs may offer.
- When using any such expert panel, it is possible that they may not fully represent the general population of subject experts.
- No input from organizational stakeholders that represent third-party payers, legislative bodies, or non-chiropractic pediatric bodies was sought.
- Expert consensus is considered a lower form of evidence, but can be helpful when higher forms of evidence are lacking.
- No specific recommendations were provided on age-appropriate treatment dosage, frequency and duration.
Dr. Thistle is a practicing chiropractor, educator, international speaker, knowledge-transfer leader, entrepreneur and medicolegal consultant. He is the founder and CEO of RRS Education, a continuing education company providing weekly research reviews, informative seminars and convenient online courses for chiropractors, physiotherapists and osteopaths around the world. He has lectured as a part-time faculty member at the Canadian Memorial Chiropractic College in the Orthopedics Department for 13 years. For questions, contact firstname.lastname@example.org or to learn more about RSS Education, visit www.rrseducation.com.
- Black LI, Clarke TC, Barnes PM et al. Use of complementary health approaches among children aged 4-17 years in the United States: National Health Interview Survey, 2007-2012. Natl Health Stat Report 2015: 1-19.
- Hestbaek L, Jorgensen A, Hartvigsen J. A description of children and adolescents in Danish chiropractic practice: results from a nationwide survey. J Manipulative Physiol Ther 2009; 32: 607-615.
- Ndetan H, Evans MW, Hawk C, et al. Chiropractic or osteopathic manipulation for children in the United States: an analysis of data from the 2007 National Health Interview Survey. J Altern Complement Med 2012; 18: 347-353.
- Gleberzon BJ, Arts J, Mei A, et al. The use of spinal manipulative therapy for pediatric health conditions: a systematic review of the literature. J Can Chiropr Assoc 2012; 32: 639-647.
- Hawk C, Schneider M, Ferrance RJ, et al. Best practices recommendations for chiropractic care for infants, children, and adolescents: results of a consensus process. J Manipulative Physiol Ther 2009; 32: 639-647.
- Shea BJ, Grimshaw JM, Wells GA, et al. Development of AMSTAR: a measurement tool to assess the methodological quality of systematic reviews. BMC Med Res Methodol 2007; 7: 10.
- Higgins JP, Altman DG, Gotzsche PC, et al. The Cochrane Collaboration’s tool for assessing risk of bias in randomized trials. BMJ 2011; 343: d5928.
- Wells GA, Shea B, Higgins JP, et al. Checklists of methodological issues for review authors to consider when including non-randomized studies in systematic reviews. Res Synth Methods 2013; 4: 63-77.
- Bronfort G, Haas M, Evans R, et al. Effectiveness of manual therapies: the UK evidence report. Chiro Osteopath 2010; 18: 3-35.
- Clar C, Tsertvadze A, Court R, et al. Clinical effectiveness of manual therapy for the management of musculoskeletal and non-musculoskeletal conditions: systematic review and update of UK evidence report. Chiro Man Ther 2014; 22: 12.
- Fitch K, Bernstein SJ, Aquilar MS, et al. The RAND UCLA appropriateness method user’s manual. Santa Monica, CA: RAND Corp.; 2003.
- Miller JE, Newell D, Bolton JE. Efficacy of chiropractic manual therapy on infant colic: a pragmatic single-blind, randomized controlled trial. J Manipulative Physiol Ther 2012; 35: 700-607.
- George M, Topaz M. A systematic review of complementary and alternative medicine for asthma self-management. Nurs Clin North Am 2013; 48: 53-149.
- Alcantara J, Alcantara JD, Alcantara J. The chiropractic care of patients with asthma: a systematic review of the literature to inform clinical practice. Clinical Chiropr 2012; 15: 23-30.
- Pepino VC, Ribeiro JD, de Oliveira Ribeiro MA, et al. Manual therapy for childhood respiratory disease: a systematic review. J Manipulative Physiol Ther 2013; 36: 57-65.
- Alcantara J, Alcantara JD, Alcantara J. The chiropractic care of infants with colic: a systematic review of the literature. Explore 2011; 7: 168-174.
- Ernst E. Chiropractic spinal manipulation for infant colic: a systematic review of randomized clinical trials. Int J Clin Pract 2009; 63: 1351-1353.
- Dobson D, Lucassen PL, Miller JJ, et al. Manipulative therapies for infantile colic. Cochrane Database Syst Rev 2012; 12: CD004796.
- Huang T, Shu X, Huang YS, et al. Complementary and miscellaneous interventions for nocturnal enuresis in children. Cochrane Database Syst Rev 2011: CD005230.