I have had a strong feeling that pediatric chiropractic is becoming increasingly popular for a while now. Unfortunately, there hasn’t been much legitimate scientific data available to help confirm or assuage my fears. A few years ago there was a National Center for Health Statistics (NCHS) survey that involved questions on the use of chiropractic by kids, as well as yoga and meditation, that were in part developed by the National Center for Complementary and Integrative Health* and gave some insight:

Among U.S. children, there was no significant difference in the use of chiropractic care between 2012 and 2017 (3.5 percent versus 3.4 percent). There were no significant differences between boys and girls in the use of chiropractic care. Non-Hispanic white children were more likely to have used chiropractic care than non-Hispanic black children or Hispanic children.

This survey further revealed that of the roughly 2 million children that were seen by a chiropractor at least once in 2017, those aged 12 to 17 years were more than twice as likely (5%) to have done so as children aged 4 to 11 years (2%).

So at least based on this data set, use of chiropractic by kids aged 4 to 17 years hadn’t been increasing, but that was 5 years ago and much of my gut feeling has been about patients younger than 4 years anyway, especially newborn infants that are being exposed to unscientific and potentially dangerous chiropractic care. This is largely based on the massive increase in the number of online marketing videos using them as props. I regularly see new YouTube videos from chiropractors discussing pediatric chiropractic, and I know that there are many more on the Instagrams, Ticktocks, and whatever else the kids are into these days.

Last month, a paper from the Journal of Manipulative and Physiological Therapeutics was published online that helps to shine a bit more light on this issue, though not much. And as you’ll soon see, we are left with a lot more questions than answers. Many thanks to Edzard Ernst for bringing this paper to my attention.

National trends in the expenditure and utilization of chiropractic care in U.S. children and adolescents

The authors set out to examine a representative sample of children and adolescents in order to determine how many were seeing a chiropractor, how often they were doing so, and how much money was being spent. They used yearly serial cross-sectional data provided by the Medical Expenditure Panel Survey from 2007 to 2016. The MEPS does involve self-reported data from individuals and families, just like the above referenced NCHS survey, but it is also verified by their medical providers and insurers. And, importantly, it looked at kids of all ages.

The lead author of the study, and perhaps the lot of them, appear to have some significant bias. In the introduction, they praise chiropractic as “one of the most utilized complementary and integrative health options in the U.S. population, with demonstrated clinical effectiveness for back and neck pain in both adults and adolescents”. They springboard off of this claim into a another that is equally dubious:

Therefore, chiropractic care is uniquely positioned to address the public health burden associated with musculoskeletal pain, and its utilization should be explored in depth.

The only problem with those statements is that they aren’t particularly accurate, or at least they are highly misleading. Chiropractic may be more popular as a treatment approach for musculoskeletal complaints than other irregular therapies, but it does not have demonstrated benefit for adults or adolescents. Nothing unique to chiropractic is effective. When helpful, chiropractors are making use of standard physical therapy and science-based recommendations such as exercise, improved sleep, and avoidance of activities that might aggravate an injury.

Furthermore, evidence in support of pediatric chiropractic for any indication is particularly lacking. This 2019 systematic review and meta-analysis came to a very different conclusion than the authors of the current study:

Based on GRADE methodology, we found the evidence was of very low quality; this prevented us from drawing conclusions about the effectiveness of specific SMT techniques in infants, children and adolescents. Outcomes in the included studies were mostly parent or patient-reported; studies did not report on intermediate outcomes to assess the effectiveness of SMT techniques in relation to the hypothesized spinal dysfunction. Severe harms were relatively scarce, poorly described and likely to be associated with underlying missed pathology.

So while severe harms may have been uncommon, they happened just as we have often predicted that they would here at SBM, by delaying appropriate care. Any risk of harm is too much when evidence of benefit is essentially non-existent. Furthermore, the proposed mechanism of potential benefit from unique chiropractic interventions for most of the reasons that they treat young children is implausible to the point of near impossibility.

What did the study find?

First off, just as in the NCHS survey, older white kids (14-17 years) were much more likely to go to a chiropractor than any other group. And boys were only slightly more likely to do so than girls. Though most had private insurance, roughly a third of children who saw a chiropractor relied on SCHIP. Of course, most of these visits were likely paid for out of pocket regardless.

There were some significant ups ($946 million in 2012) and downs ($317 million in 2008), likely related to the Great Recession of the late 2000s, when looking at expenditures. From 2007 to 2016 there was a yearly increase of about $22 million spent on chiropractic care for children, but this result wasn’t statistically significant enough to claim with confidence that there has been true growth. Regardless, people are spending a lot of money on nonsense even if expenditures for pediatric chiropractic only make up about 3-4% of the total.

When looking at how many kids were seen by chiropractors over this time period, there was a lot of variation from year to year, with a difference of roughly 600,000 children between the peak (1.48 million in 2015) and the valley (864,000 in 2011). Analysis found that there was a statistically significant yearly increase of about 50,000 children, however. The total number of pediatric visits ranged from 4.32 million in 2008 to 12.44 million in 2012, with the year-to-year growth using linear regression analysis being essentially stagnant.

The final bit of statistical analysis I’ll mention is percent utilization. The authors found that the percent of U.S. children that saw a chiropractor during this 10-year period ranged from 1.17% in 2011 to 1.99% in 2015, and that there was a statistically significant increase of .064% each year. Again, this was found using a linear regression model. The total percent utilization was lower than what was found in the NCHS data I mentioned earlier, but that is because this MEPS data goes down to birth. Younger children (.37% to 1.12%) are much less likely than older children (1.3% to 2.3%) to see a chiropractor, so the utilization is diluted.

The elephant in the room

There is a huge limitation when it comes to the conclusions of this study. Unfortunately, it focuses only on pediatric visits to a chiropractor, and expenditures for their services, in the setting of musculoskeletal complaints. In fact, each visit was linked to a specific but partial ICD-9 code, which allowed the study authors to lump them each into one of 6 broad categories, such as “head and neck” or “curvature of the spine”.

While it is true that most chiropractic visits for older children likely involve problems like neck and back pain, virtually all infants and very young children do not. Infants in particular are often seen for complaints such as fussiness, reflux, feeding problems, sleep problems, or for a desire to boost a babies’ immune system. Toddlers and school aged children are also commonly seen for non-musculoskeletal complaints, such as bedwetting, ear infections, or concerns about overall health and development. It’s possible that some or many of these visits were coded as a musculoskeletal problem, but some visits might have slipped through the cracks. This study doesn’t add any helpful insight when it comes to this issue.

Conclusion: we need better and more current data

Unfortunately, this new study doesn’t add much to our understanding of the utilization of pediatric chiropractic, though I don’t believe there has been anything else published on the pediatric chiropractic-specific expenditures. The data is essentially in line with the earlier published NCHS survey results and doesn’t support any claims by chiropractors that parents are beating down their clinic doors. There may have been some modest increase in the total number of kids going to a chiropractor from 2007 to 2016, but the total number of visits and total amount of money spent on them doesn’t appear to be on the rise.

Still, there were thousands of kids and millions of visits every year during this period. And millions were spent, even if was a fairly small percent of the total expenditure for chiropractic care. And this new batch of numbers doesn’t address my concern that social media is both a cause of, and a window into, increasing numbers of very young children, even newborn babies, finding themselves being poked and prodded by a fool with delusions of expertise and considerably more confidence than good sense. I’m sure it’s not a huge number by any stretch, though of course one is too many in my opinion. But it’s a number that should be tracked.


*Previously known as the National Center for Complementary and Alternative Medicine. Before that it was the Office of Alternative Medicine, which began as Senator Tom Harkins’ bee pollen-inspired pet project.

Author

  • Clay Jones, M.D. is a pediatrician 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 @SBMPediatrics and is the co-host of The Prism Podcast with fellow SBM contributor Grant Ritchey. The comments expressed by Dr. Jones are his own and do not represent the views or opinions of Newton-Wellesley Hospital or its administration.

Posted by Clay Jones

Clay Jones, M.D. is a pediatrician 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 @SBMPediatrics and is the co-host of The Prism Podcast with fellow SBM contributor Grant Ritchey. The comments expressed by Dr. Jones are his own and do not represent the views or opinions of Newton-Wellesley Hospital or its administration.