A significant part of my job as a pediatric hospitalist involves caring for newborns. It is arguably the best thing that I get to do as a physician, even if I do at times prefer the increased intellectual stimulation of the ill hospitalized child. While seeing newborns, I am almost always surrounded by happy and appreciative parents, grandparents and whoever else is invited to meet and greet the new arrival because the babies are almost always healthy. In fact, and not that I really care (sniff, sniff), the parents of newborns are with rare exception the only caregivers that ever thank me at discharge.
Unfortunately, sometimes I am called upon to assist babies that are having difficulty transitioning into the outside world for a variety of reasons. These reasons can range from the fairly minor and transient to the catastrophic. And despite our advances in the understanding of neonatal pathophysiology and in medical technology, there remain newborn infants that cannot be saved or who have severe lifelong deficits caused by their illness or injury. This will likely always be the case, especially if unqualified professionals continue to involve themselves in either the delivery or the care of babies.
Over the course of 11 years of practice, and after having seen thousands of both perfectly healthy and severely ill newborns, I have acquired a skill set which allows for the recognition of a baby in trouble and the ability to respond appropriately. All pediatricians and family doctors strive to develop this, particularly if they see patients in the newborn nursery, although I imagine none, including myself, would claim to have perfected this “art”. Newborn medicine can be very challenging for many reasons, not the least of which is the significant overlap of the presenting signs and symptoms of many serious conditions, with even normal baby behavior sometimes mimicking potentially life-threatening pathology.
Take a fussy or jittery baby for example. These are common symptoms often experienced as part of normal newborn behavior or related to environmental insults such as hunger, overstimulation, or a wet diaper. Frequently babies are fussy for no apparent reason at all, and normal newborn findings like the Moro reflex and startle can be exaggerated but within the wide range of what is normal. But fussiness or jitteriness can be the presenting symptoms for hypothermia, hypoglycemia, hypocalcemia, opioid withdrawal, meningitis, pneumonia, sepsis, necrotizing enterocolitis, a collapsed lung, a broken clavicle, hemorrhaging into the brain, a twisted testicle and much more.
While it is true that there are often historical clues or additional exam findings that can help differentiate the many possible causes of a newborn’s signs or symptoms, it isn’t always the case. Sometimes helpful clues develop over time, but time isn’t always a luxury we have. Waiting for a blood culture to become positive or for a baby to develop hypothermia and seizures before starting antibiotics would result in some very poor outcomes.
Healthcare professionals who care for newborns are trained to deal with most of the complications that can arise in the immediate period after a baby is born. We are qualified in neonatal resuscitation and regularly maintain our skills by attending classes and taking part in simulated cases. And again, we see actual sick babies. Some of us, particularly neonatologists, see a lot of them.
I tell you all this to provide some insight into my utter revulsion at the concept of chiropractors taking part in the care of any newborn infant, let alone one that might require medical intervention to save their life or prevent long-term complications. I realize that readers of Science-Based Medicine are almost certainly aware of the push by many practitioners of so-called alternative medicine to be accepted as a primary care provider or PCP. There are a number of posts that discuss their legal tactics by Jan Bellamy, for instance. And several that point out the absurdity of it all considering the lack of a fund of knowledge and appropriate training that could even remotely qualify them to successfully prevent or treat real medical problems, as opposed to their litany of fictitious ailments.
For this post, which is coming out on the 14th consecutive day that I will spend caring for newborns and hospitalized children, I wanted to provide readers with an example of why the chiropractor as a PCP, specifically one that involves themselves with newborns, is such a dangerous concept. And while I haven’t spent as many years exposing myself to the world of chiropractic foolishness as some of my fellow SBM contributors, in my opinion this one is up there with the worst of the worst.
A pathway to disaster
Pathways to Family Wellness is a magazine published quarterly by the International Chiropractic Pediatric Association, who according to their website is essentially the American Academy of Pediatrics for chiropractors:
The ICPA is a nonprofit organization whose mission is to advance chiropractic by establishing evidenced informed practice, supporting excellence in professional skills and delivering educational resources to the public. It fulfills this mission by engaging and serving family chiropractors worldwide through research, training and public education.
In reality they do none of this. Their evidence base almost exclusively consists of case reports and the education they provide is largely self-serving. They provide resources which help chiropractors expand their panel of customers by recruiting children as patients. Their biggest claim to fame is that they offer certification (certifiction?) and diplomate programs in pediatric chiropractic.
Pathways is mostly just a magazine to put in the waiting room, hand out at health fairs, or leave in piles at local grocery stores with a flier for your practice tucked inside. It’s propaganda. The article in the Summer 2014 issue that I want to focus on, “A Touch to Heal: A Chiropractor Helps Direct an At-Risk Newborn Toward Wellness “, is an abomination that perfectly illustrates everything that is wrong with both chiropractic in general and their nonsensical goal of being taken seriously in the role of primary care for children. I’ll be honest and say that I think, like the chiropractic subluxation itself, this article is fiction. I think it’s almost certainly either extremely exaggerated or completely made up as part of a practice building scheme for an individual practice. In fact, here is strikingly similar anecdote from an earlier issue of Pathways.
A touch to fear
Written by chiropractor Ryan Dopps, “A Touch to Heal” takes us through a night in the life of an apparently always on-call chiropractor:
The text came through at 10:41 p.m. on a Friday night. It was from our midwife, Michelle Ruebke, C.P.M.: “I just delivered a baby and think he needs to see one of you guys. He’s too fussy (not crying) and won’t nurse.” Instantly I turned to my wife, who is also a chiropractor, and with little discussion I was out the door. On my 40-minute drive north to Michelle’s rural home, my thoughts were already fixated on this little person, preparing my heart and mind for what was to come.
Just to clarify this introduction, a baby was delivered at the home of a midwife apparently nowhere near a proper medical facility. And the worried midwife called a chiropractor who lives almost an hour away for help. This is truly the blind leading the blind. An irritable or extremely fussy baby could be very ill (see earlier differential for the fussy baby). Also, I’m a bit confused regarding just what it means when a baby is excessively fussy but not crying. Is the baby not crying because of respiratory depression? Is their airway partially obstructed? Do they have ischemic encephalopathy? Instead of preparing his heart and mind, he should be reviewing his PALS and NRP algorithms.
Michelle was an experienced midwife who had delivered over 600 babies. She even had delivered the children of chiropractor Dopps. Despite this experience, and the confidence to deliver babies at her home in the country, she was apparently very worried about something. Of course, with 10% of babies requiring a little help to start breathing but less than 1% needing significant resuscitation, it isn’t impossible that she could have delivered 600 babies without incident, especially if she only took care of very low risk mothers.
Chiropractor Dopps surveys the scene:
A baby boy, only hours hold, was swaddled tightly and very agitated, struggling to get out a cry. He would not nurse and was having spasms in his arms. Asking questions about his birth and the time since then, I dove right in. His respiration was fast and his head was misshapen, more so than in most newborns. “He only shows his whimper if we place our hands on his head,” Michelle said.
There is a lot to unpack here. Again, an “agitated” baby could be very ill, but then again I don’t trust that they have the ability to differentiate normal crying/fussiness from irritability/agitation. And describing his arm movements as spasms is very unhelpful. Was the baby having normal or exaggerated intermittent reflex motor activity, benign sleep related myoclonic jerking, or actual seizure activity? What questions about the birth did he ask, I have to wonder. Certainly chiropractic education doesn’t teach about prenatal, delivery and postnatal complications that can lead to difficulties, or at least they can’t get into too much detail during the weekend learning about newborns as part of the ICPA diplomate program.
Also, how does he know what most newborns heads look like? I routinely see significant, even scary, molding of the scalp. This occurs because the bones of the skull are not fused together and can move around because of the pressure of a vaginal delivery, often forming a cone shape. It has no clinical significance when this occurs and resolves within several hours to a couple of days with no intervention. The baby could have had swelling of the scalp, called caput, or a collection of blood under the thin but tough outside layer of one or more of the skull bones. Cephalohematomas, as they are called, unless huge are almost always of no clinical concern and resolve over the first few weeks of life. All newborns breathe fast compared to older kids and adults, with the upper limit of normal being 60 breaths per minute. Did this kid have true tachypnea (faster than normal breathing rate)?
The plot thickens:
When I checked the newborn I found a right lateral atlas subluxation, as well as a misaligned right mastoid fontanel. The parietal and occipital bones were overlapping each other to the accord of a half inch. With a gentle but purposeful touch, I adjusted the cranials and the atlas. The right lateral atlas set into place with a profound thud. I’ve never experienced a newborn’s atlas moving the way this child’s did. I knew innate was being unleashed to express vitality through his body.
It’s getting real now. It is very likely that the only thing Dopps felt was the power of his own imagination. He expected there to be a vertebral misalignment, so there was one. And again, baby skulls are made to move around. If not, they would be at significant risk of becoming stuck when moving through the mother’s pelvis. It isn’t a design flaw, it’s a safety feature necessary because of our big brains.
A misaligned fontanel is a meaningless term that has no clinical significance. A fontanel or “soft spot” is one of a few of the larger sutures, or spaces between the largely unfused skull bones. As stated earlier, their presence allows for a malleable and more easily-delivered skull but also the ability of the cranium to expand as our big brains get bigger. They also allow for ultrasound of the brain to be a viable imaging modality in young infants and for a possible clue that a baby is dehydrated (sunken fontanel) or has meningitis or some other cause of increased intracranial pressure (bulging fontanel).
It takes a lot of pressure to move the skull bones around. To actually believe that a gentle touch “adjusted” anything, let alone the “cranials” or the first cervical vertebra (the atlas), is as plausible as water memory or transferring healing human energy fields by email. Also extremely unlikely is the possibility that this child had displacement of the atlas in the first place. A true subluxation of C1 or an actual fracture usually occurs only with major trauma, such as after diving into unexpectedly shallow water or with extreme rotation of the neck, but can result because of a variety of congenital or chronic inflammatory conditions over time.
Depending on the direction and severity, this can be a fatal injury if the vertebra compresses or transects the spinal cord traveling through it. It doesn’t happen often during delivery, but it can, and it is a medical emergency with an overall mortality rate of 16%. The description of this child’s problems actually does overlap a little with a possible C1 injury (difficulty moving arms, abnormal breathing, apparent pain). It’s a bit of a stretch, but any manipulation of a neck with a C1 injury can result in complete paralysis and an inability to breathe. I doubt that Ruebke and Dopps (worst premise for a TV show ever) would have been prepared to intubate and bag this kid until an ambulance or Life Flight arrived.
During the rest of the encounter, chiropractor Dopps ends up adjusting the child’s neck two additional times until the atlas “held” but also finds subluxations in both the ilium (one of the hip bones) and sacrum that need correcting. Thankfully his adjustment of the mastoid fontanel held strong. Eventually the baby is crying normally, feeding like a champ at the breast and no longer having “uncontrolled arm movements.” At one point the baby is described as having “inflammation on the vertex”, a phrase that when put into Google can only be found in this particular article. I guess now there will be two occurrences. I think what he is talking about is the common finding of some skin discoloration, often somewhat reddened, at the point of maximal pressure during a vaginal delivery, usually the top of the head which is called the cranial vertex. He refers to it as if it’s a problem and that his adjustments helped it “settle down”.
Sprinkled throughout the anecdote are phrases that really stand out as examples of how chiropractic, like many systems of alternative medicine, share more in common with religion than science or medicine. “I knew innate was being unleashed to express vitality through his body.” Innate being the “straight” chiropractor’s raison d’être. It is the healing force of nature/God that flows into our bodies and through a healthy spine into every nook and cranny. The chiropractic adjustment removes impediments to this otherwise all-powerful entity in the same way that acupuncture needles treat stagnant chi by unblocking meridians, which is to say that they work via theatrical placebo.
The most egregious examples of the arrogance of ignorance inherent in being a chiropractor that is comfortable caring for an “at-risk newborn” comes when Dopps, in awe of his own healing abilities, writes “That is the truth; the newborn was at peace when my hands were working” and “Your baby is in my hands now, and he’s going to be just fine.”
Dopps finishes up with a not-unexpected dig at conventional medicine and yet another example of the vitalistic religiosity of chiropractic philosophy:
On my drive home early Saturday morning, I was humbled by the chiropractic principles that I live for. That there was no bag of medicine, no needle full of whatever, no brain-function monitor that I could have brought in a little black doctor bag that had more intelligence than what was inside that brand-new baby boy. It is good work that we do. With these hands, innate can be the doctor.
I feel compelled to again mention the fact that I think that this particular anecdote is likely greatly exaggerated by Dopps for the effect of coming across as a knowledgeable savior for a newborn baby in serious trouble. He did heal with the gentle touch of his hands, after all. Although everyone knows that Jesus was really just a Reiki Master. It may simply be completely made up. Either way, it demonstrates his poor understanding of how babies work and the potential dangers of what might happen should he or any other chiropractor find themselves in the position of caring for a truly ill or injured newborn.
The story also illustrates how risky an at home delivery is. The midwife in question was clearly terribly unprepared and this child could have easily suffered severe neurologic sequelae or even died considering how many really bad things can present like he supposedly did. So if you weren’t already incensed at the thought of the chiropractic profession achieving their goals of serving as the PCP for children, I truly hope that you are now.
Here is a video demonstrating a chiropractic exam and spinal adjustment of a baby that is supposedly 5 hours old. I will go ahead and let you know that there is absolutely, under no circumstances, any indication to hold a baby up in the air by one leg to see which way their head turns. He just keeps doing it until the kid happens to look the other way and then claims to have successfully corrected the pressure on the baby’s brainstem. This is what we are dealing with. This is what we must deal with.