birth subluxation

I had the pleasure of speaking on the topic of chiropractic and the newborn baby earlier this week at a meeting of the Boston Skeptics. There is a video of the talk online for anyone interested in learning more. And if you haven’t yet, please read yesterday’s post on chiropractic and babies by Sam Homola.

My introduction to pediatric chiropractic

Although I was aware of the existence of chiropractic well before beginning my medical training, I was blissfully ignorant of the full scope of what many chiropractors actually do on a daily basis. My belief that they practiced solely as “doctors of the back” was shattered early in my pediatric training at Vanderbilt while on a pulmonary medicine rotation when I was asked to consult on the child of a well-known musician who lived in the area. The patient, perhaps only hours from respiratory failure, had been brought to our emergency department only after chiropractic treatments had failed to manage a severe asthma exacerbation.

That encounter, as well as another around the same time involving a child with a throat abscess being treated with acupuncture, inspired me to dig deeper into the general concept of alternative medicine. I even went so far as to approach a local chiropractor who had set up a table at a Nashville YMCA to promote chiropractic prevention and treatment of the flu. Dr. Fakename happily allowed me to spend a day in his office, and even brought in his own child to demonstrate his approach pediatric care.

Needless to say, Dr. Fakename failed to convince me of the benefits or need for chiropractic involvement in pediatric healthcare. When the discussion turned to routine childhood vaccines, I heard the party line on the subject for the first of many times. Dr. Fakename was not against vaccines, he was in favor of giving families all of the facts. He gave me some reading material, and a book suggestion or two, which provided nothing but potential and unproven risks with no mention of the well-established benefits and proven safety of immunizations. I’ll never forget what his wife, who had brought their child in for the demonstration, whispered to me during a moment of distraction: “Don’t worry, we vaccinate our kids. I make sure.”

By the end of my residency I was a full blown skeptic of a variety of alternative medical modalities in addition to chiropractic, and had built a reputation as someone interested in and knowledgeable on the subject of quackery. I even gave a grand rounds on pediatric CAM with a focus on chiropractic which I’m proud to say drew a standing room only crowd that included folks from the community interested in alternative medicine as well as from the brand new integrative medicine center at Vanderbilt. I had even been asked to serve as a resident representative, however that invitation was quickly rescinded after my skeptical talk.

My particular interest in the chiropractic approach to newborn medicine came about by chance. While I still do care for hospitalized children of all ages, the primary focus of the majority of my career so far has been taking care of well newborns. The discovery of newborn chiropractic as an entity, while not as shocking as my initial exposure to pediatric chiropractic in general back in residency, was still surprising. And I continue to be occasionally surprised as I research this area of irregular medicine over a decade later. I always think I’ve found the worst example of their irresponsible and potentially dangerous interactions with children, only to be proven wrong time and time again.

Why do some chiropractors focus on newborns?

There are many explanations, ranging from the overly generous to the rather cynical, for why I believe that many in the chiropractic community target the newborn population. Probably the majority of those who see babies truly believe in the nonsense they are telling parents, putting on their websites, or uploading to YouTube. Perhaps they really do accept the existence of subluxations and that they are the root cause of myriad health problems in young infants, problems as diverse as difficulty breastfeeding, colic, and even sudden infant death syndrome. People are generally the heroes of their own narrative, so it is quite likely in fact that the vast majority of practitioners go to sleep at night feeling like they are helping parents and improving the lives of children.

Because of a history riddled with counter-examples and the widespread availability of solid evidence disproving the totality of chiropractic claims when it comes to newborn care, I can certainly understand why some might approach this question a bit less charitably. Practice building is a notorious aspect of chiropractic training and the running of their clinics after all. It is extremely easy to find examples of this relating to pediatric care, where the focus on children is treated more as a business opportunity than a calling. Convincing a parent who goes to a chiropractor to bring in the kids next time is a great way to increase patient rolls and profits.

How is chiropractic for newborns presented to parents?

Regardless of their intention, a chiropractor’s decision to treat newborns is particularly upsetting to me for obvious reasons. Parents are an especially vulnerable population in my opinion, and chiropractors are hardly alone in their attempts to convince them of questionable claims. A walk through your local Babies”R”Us should convince anyone of that sad fact. The primary tactic, whether trying to sell “The Big Idea” of chiropractic or a useless home monitor that won’t actually prevent SIDS, is always fear.

As discussed by Sam Homola in his post yesterday, the subluxation remains the fictional boogeyman used to convince parents of the need for chiropractic evaluation and treatment. Newborn and very young infants, they claim, acquire subluxations of the spine during the arduous birth process or during routine care such as changing a diaper. Even proven safety interventions such as the use of an infant car seat are potentially to blame!

But birth is the clear favorite when it comes to explaining why a baby is at risk for having a subluxation. Whether born via c-section or vaginal delivery, emergence into the world generally requires pulling on a child’s head, which can require a fair amount of force. As I explained in my discussion with the Boston Skeptics group, babies can acquire traumatic injury during delivery, such as clavicle fractures and injury to the nerves that supply the arm or diaphragm. And even without injury the significant pressure involved can transiently move the bones of the skull into a variety of odd shapes. This nugget of truth is well known to most parents and it is easy to understand why some caregivers are convinced that even seemingly uneventful deliveries might cause problems in a child’s spine.

Once the possibility, or more typically the extreme likelihood of a subluxation being present is accepted, parents are then made aware of what might come to pass if the condition is allowed to go untreated. Which pediatric conditions are claimed to be amenable to chiropractic care depends on the chiropractor, and can range from everything (even cancer) to a limited list that most commonly includes problems such as ear infections, bed wetting, constipation, sleep problems, asthma, weak immune function, and of course musculoskeletal complaints. In the newborn population, problems such as fussiness/colic, difficulty breastfeeding, torticollisreflux, and sleep difficulties are common.

Some chiropractors go much further, even claiming to be able to prevent life-threatening outcomes by detecting and correcting so-called silent spinal subluxations. I’ve written in the past about such examples: SIDS and “shaken baby syndrome” caused by routine care or play. SIDS and abusive head trauma (what we now call shaken baby syndrome) are two of the very worst issues that pediatricians and parents face and the thought of families living in fear that their perfectly healthy child is at increased risk of death or permanent neurological injury unless they have regular chiropractic adjustments makes me very angry.

Of course not all parents actually need convincing. Probably the majority of newborns seen by chiropractors are born into families who already see a chiropractor themselves and have bought into the concept of subluxation and “spinal health.” Many mother’s of infant patients underwent chiropractic care during the pregnancy.  A common theme used by chiropractors is to compare themselves to a dentist, pointing out how dental visits take place regularly even in the absence of symptoms in order to prevent cavities or to catch problems before they become significant. It’s a convincing tactic.

What happens during a newborn’s visit to the chiropractor?

Whether in the hospital (it happens!), at home (another one), or in the office, newborn chiropractic visits tend to involve a similar format. The most powerful part of the process, much more so than the actual adjustment to be honest, involves the laying on of hands. The chiropractor palpates the spine and checks movement of the neck and various joints. They may compare leg lengths or even hold the baby upside down (another one) in order to see how they turn their head. As they go they talk through what they are doing, usually commenting on findings such as tightness or restrictions and always explaining what problems a baby might experience because of subluxations. It can involve a fair amount of absolute nonsense.

There is a lot of cold reading that goes on during these visits which can give the impression that the chiropractor’s examination uncovered problems like constipation or colic. Most of the time the parent has told the chiropractor what the problem is and naturally the cause, a subluxation, is discovered at just the right spot to explain it. Some do a better job than others. Often the chiropractor reacts to random non-purposeful movements, yawns, crying, etc. by working it into the narrative. If a baby begins to cry during palpation, they found a bothersome area. If the baby happens to stop crying, the adjustment did the trick. There are countless examples of this evident on the hundreds of encounters I’ve see online and the few I’ve witnessed in person.

If you watch only one of these videos, make it this one. The chiropractor has an amazing bedside manner while discussing his evaluation. He really does do it all. Cold reading. The laying on of hands. Confidently describing complete nonsense. It’s truly a thing of beauty. He is all about the long game as he appears to say that the baby won’t need any adjustments at that visit, although as the video ends he seems to back track a bit. Here he is again explaining a specific newborn chiropractic technique and some underlying pathophysiology that it is almost complete baloney.

What is the chiropractor feeling during the assessment? They certainly aren’t feeling subluxations, as there is no good evidence to support that they exist in the chiropractic sense. They also aren’t feeling actual restrictions in movement with perhaps the exception of congenital torticollis, where a baby has difficulty fully turning the head. But this problem has nothing to do with the spine but rather unilateral injury to a muscle in the neck. In my opinion, and assuming that they aren’t knowingly deceiving the caregiver, they are simply feeling what they want and expect to find.

The adjustments performed on newborns and young infants are, in most circumstances, very gentle. This makes sense considering that many parents would be likely to bristle at vigorous high velocity adjustments to their baby’s neck or to loud popping sounds coming from their back. In fact, most chiropractic websites and videos that discuss newborn or pediatric chiropractic in general go to great lengths to separate it from the typical adult adjustment.

Chiropractors tend to use almost imperceptible adjusting force in babies, usually with their fingertips. They often claim to use an amount of pressure equivalent to checking for ripeness in a tomato, for example. Many use an adjusting tool like the Activator, a handheld spring-loaded thumping device. The latest model, a cordless electric version, costs a little over $1,500.

Sadly, the gentler approach so common in pediatric chiropractic isn’t ubiquitous. This video demonstrates a clearly painful adjustment of a 2-week-old infant using more substantial pressure. Here is another, which at the 2:00 mark shows a painful jerking adjustment of the neck of a different 14-day-old baby.

Is there evidence for newborn chiropractic care?

As with most indications for chiropractic intervention touted by practitioners, there is very little actual science to support their claims. If the basis of a treatment is finding and correcting the fictional chiropractic subluxation, then there is a lack of plausibility such that efforts to investigate the treatments have been and continue to be a waste of time and money. Treatment provided by chiropractors that is not subluxation-based often consist of other forms of alternative medicine such as acupuncture and herbal or homeopathic remedies that are equally unsound.

In the case of newborn care specifically, there is very little literature to evaluate. What does exist consists mostly of case reports, uncontrolled studies, and systematic reviews published in questionable journals. Thousands of anecdotes and testimonials are available on the websites of individual chiropractic practices however. I very recently stumbled on this study, which revealed to me that chiropractors are diagnosing “benign infant headache” in 2-day-old babies. It is a perfect example of how woefully inadequate their training in pediatric medicine is.

What’s the harm in bringing a baby to the chiropractor?

The ultimate problem with newborn chiropractic care isn’t that these babies are at high risk of direct injury to their developing backbone and spinal cord from aggressive manipulations, although it is a risk and it does happen. Steve Novella has written about such a case before. Here is another scary example where a child likely had their ribs fractured by an adjustment. So it does happen.

The more concerning issue is the indirect risk of missing a serious diagnosis or trying to treat a known life or limb threatening condition, both of which would delay access to appropriate medical care. The above cited headache study is a prime example. Their description of “benign infant headache,” a diagnosis which exists only in the minds and literature of chiropractors, is a prime example of this. Chiropractors, even when they go through post-graduate training in pediatrics in order to claim special designation, obtain a small fraction of the exposure to children, let alone ill children, that pediatricians and family doctors receive. There is simply no comparison whatsoever.

Another issue is that chiropractors who see children are often either overtly anti-vaccine or sneaky about it. They provide “education” that consists only of the risks. Were they to achieve primary care practitioner status I worry that vaccine rates among the subset of infants seen by chiropractors would drop even further. Disparaging conventional medical advice is also common. More babies being seen by chiropractors would likely lead to more families questioning other standard pediatric medicine recommendations because of unwarranted fears.

Conclusion: Chiropractors have no role in newborn care

The bottom line when it comes to newborn chiropractic care is that there is no role for it under any circumstances. There is, despite the claims of many in the chiropractic community, no evidence to support any indication in children that young. And although the risk of serious traumatic injury is low overall, it is not zero. And it will increase as more infants are brought in for evaluation and treatment of phony problems like the subluxation.

Their sometimes impressive demonstrations to families are packed with misinformation and are often designed specifically to bring in customers. Once a regular patient, any child who is truly ill is at risk of delayed care from a provider actually trained in pediatric medicine. And as more families are influenced by chiropractic vaccine misinformation, more children will be at risk for preventable and sometimes deadly diseases. Your child’s spine will most certainly be just fine without chiropractic care.

 

 

Posted by Clay Jones

Clay Jones, M.D. is a pediatrician practicing at Newton-Wellesley Hospital in Newton, MA, and a regular contributor to the Science-Based Medicine blog. He primarily cares for healthy newborns and hospitalized children, and devotes his full time to educating pediatric residents and medical students. Dr. Jones first became aware of and interested in the incursion of pseudoscience into his chosen profession while completing his pediatric residency at Vanderbilt Children’s Hospital a decade ago. He has since focused his efforts on teaching the application of critical thinking and scientific skepticism to the practice of pediatric medicine. Dr. Jones has no conflicts of interest to disclose and no ties to the pharmaceutical industry. He can be found on Twitter as @skepticpedi and is the co-host of The Prism Podcast with fellow SBM contributor Grant Ritchey.