HealthPhilosophy

A Statement on Chiropractic Care for Infants and Children

A Guest Post by Dr Amanda Stevens, Developmental Chiropractor

There has been a lot of fuss in certain circles about threats to practicing chiropractic care in the pediatric population (in Canada and oversees).  I’m a pretty small fish in this “pond”, but I seem to get called out for a response periodically (maybe because my practice focuses entirely on pediatric and pregnancy care), so here are some of my thoughts on the matter, mostly put down so that I can clear them out of my head.

When you have a journalist who is used to reporting on war-torn travesties and injustice, the reality in this situation is just not going to be newsworthy or entertaining.  I try not to get caught up in popular reporting (and in the news in general).  These kinds of stories come and go with varying degrees of traction and they seldom provide a complete picture.  I would like to maintain faith that our regulating bodies are making their decisions based on thorough scientific review, professional considerations, and logic (though I admit sometimes it is difficult to see this due to lack of transparency or explanation of their process).

Anyway, here is the punch line before we even get started:

This is an opportunity for pediatric care to STEP IT UP.

What is the problem?

Good question. I will not pretend to have a full grasp on the complex dynamics at play here, but from my where I stand, this is what I see:

  • Public protection and perceptions.  It is the responsibility for the CCBC to protect the public. That is their job. Any time there is a real or perceived threat, especially to a vulnerable population, they must take that seriously and do something to show they are paying attention and taking action, if warranted. The process of how they go about this and how they communicate both their process and their decisions to members of the profession and the public could certainly be scrutinized, but we need to remember that their mandate is to protect the public, not promote the profession.(That is what the BCCA is for.)

The CCBC's Mission Statement

The CCBC serves and protects the public and governs the delivery of chiropractic health care in BC by:

Ensuring the highest professional standards;

Advancing continued education and research; and

Promoting and enhancing collaborative relationships.

  • A lack of understanding.  Pediatric chiropractic care is not something that the majority of people have been exposed to directly. I have a lot of nervous parents coming in for their infant’s first visit who get referred by other professionals in town. I can say with confidence that I do not have nervous patients leaving our office.  We take a lot of time during that first visit - not just to review their concerns, take a thorough history, and provide an extensive physical exam - but to educate them on what we are doing and why and how. We take time to review infant anatomy and discuss (before there are any hands on baby) exactly what the treatment will look like.  People calm down very quickly once they understand the what, why, and how. The preconceived safety notions get put into perspective when they see how gentle our treatments are (and see how their children respond).
  • Fear and catastrophizing.  You throw inflammatory news and pop culture articles on top of a lack of understanding and awareness and the problem gets a lot bigger and uglier. You throw angry and emotional chiropractors who feel their life’s work is being threatened into the mix… now it is volatile.  You also have people within the profession with varying opinions and level of understanding and exposure to pediatric care (and who, for very good reason, want to distance themselves from some of the more outrageous outliers). There are so many more angles that fear can present, but how it is expressed and what is done about it matters more to me.  (I also have a reputation of being allergic to drama, so my leaning toward low-emotion logical, non-violent conversation comes almost compulsively.)
  • Discernment.  Chiropractors have been treating children since 1895 and manual therapy has included the treatment of children for likely longer than we have record. A lot has changed since then and we have evolved as a profession and as a modern world.  Our discernment in intelligent marketing claims (and even our understanding of what we do) needs to evolve as well.  I believe a big part of how we got into this mess was lack of discretion by some chiropractors in their claims more so than their treatment (as well as a lack of progression in that actual practice of care for infants, but I’ll get to that in minute).

How do we fix it?

Another good question and one that I will not claim to have the answer to, but as someone who has been focusing on pediatric care for the last decade, here are my two-cents.

In the big picture: More and better education & research.

1. Education

EDUCATION IN CHIROPRACTC COLLEGE

  • CORE CURRICULUM: I feel that at Palmar West (my alma mater) we had a good pediatric teacher and a good core curriculum course in pediatrics.  During this course, we mostly covered how to rule out red flags (which is obviously very important in pediatric case management), how to do a standard infant exam, and one very gentle but useful adjusting technique. Respecting everything that they learned in that class, a general family practice chiropractor should be able to know when to refer an infant out and is capable of honouring their oath to do no harm.  From talking with other chiropractors from other schools, it seems the level of quality in their core curriculum pediatric course varies quite a bit. This course is basic, but important for establishing safe practice with children and it is important for our scope to be inclusive.
  • ADVANCED ELECTIVES: In my opinion, at any school that I am aware of, the core curriculum training is not enough if you want to focus your practice on pediatric care (although I am hearing good things about the UK college).  It is simply not enough depth.  This is not an area that everyone is interested in practicing, but I would love to see more schools offering advanced electives in pediatrics. I have a feeling they would be VERY popular courses and would really help equip chiropractors in ethical, safe, and effective pediatric care.  I think this would be a really useful step in stepping up our pediatric game right from the gate.

POSTDOC EDUCATION

  • We need more and better. Period. There are a few programs around the US (and oversees, but I am not familiar with what they have to offer over yonder). I’m not aware of any organized pediatric courses that are initiated from Canada. Most of these programs are entry-level courses, meant to support family chiropractors who want to work with the infant population. We could get into a discussion on the variations in philosophy and academic depth, but this is a good place to start. It is not a good place to end.
  • I feel a move toward more organized advanced certificationswould be a positive and logical next step. In Canada, that could mean the development of a Pediatric Residency program. This is a big undertaking as completing a residency program is akin to taking a Master’s degree, but I would LOVE to see this happen. (BTW, if that is something you are interested in or you know how to start that ball rolling, please contact me!) Internationally, there certainly could be room for a global certification program as well (perhaps following the model of what FICS has for sport chiros).
    • My husband also pointed out that there could be a program similar to the additional acupuncture training that is available within the scope of certain provinces. I’m not sure if this would mean though that only people who have taken that course are allowed to treat children under a certain age. Interesting thought though. I’m not sure how it would materialize. From my understanding, that type of additional course work has more to do with treatment being covered under scope/malpractice insurance, whereas, in Canada, a residency designation is the only way you are allowed to publicly advertise that you specialize.  (Notice that even though my practice focuses entirely on peds/pregers and I have taken thousands of hours of additional training, I still make no claims that I specialize in pediatrics because that is not allowed under Canada’s chiro marketing rules.)
  • I will tell you a little more about what I have done for postdoc course work in a bit, but the bottom line here is that there is a need to responsibly equip chiropractors with more and better high-quality pediatric education in and out of chiropractic college.

Pediatric practice is about so much more than “liking kids”. There is a difference between a GP and a paediatrician. They are both important and they both have their roles. Without taking away from the importance of chiropractic general family practice, we need to start equipping chiropractic “pediatricians”.

2. Research

I was made aware recently that there is a very strange thing happening amongst a certain population of chiropractors (mostly in the US, apparently).  Basically, their feeling is that because they see the results that they see and because they have a strong emotional belief in what chiropractic care has the potential to do, they feel there is no need to research.  This shocked me. I’m baffled at the premise of this type of thinking (the same type of thinking that would lead us to believe that the earth is flat). I guess I have always been a bit of a dork and I never seem to be able to get enough of academia and the pursuit of knowledge.  I fear this philosophy has and is going to continue to cause problems for our profession.

The trouble here is that,

(1) Chiropractic is not a belief system.  I am not the Easter bunny. I do feel that our thoughts are important and that they impact our health and response to care, but that is not the operating principle of my work. My job, as a chiropractor, in a nutshell, is applied anatomy.  I go through years of training to learn what “normal/ideal" is for the human NMSK system, I discern any deviations from that ideal, and then I attempt to restore that system to a more “ideal” state so that the body and brain can work to their fullest potential. Whether working with torticollis or low back pain in pregnancy, I could describe how my approach fits within those parameters. It is pretty straight forward. Just like engineering and dentistry, chiropractic is a profession and field of study, not a religion.  It is based on science and the clinical application of it.

(2) That is not the way the world works.  In order for patients to fully consent to care, they need to understand what you are doing and why. It takes research and study to be able to answer and explain. That same research also guides us as practitioners toward the best treatment approaches. It is also important to have high quality evidence (and to be able to articulate it) to ensure access to care.  We are a regulated profession. For government and insurance agencies to provide access, they need supportive evidence. This research also has the capacity to influence our scope.  Plus, I just really want to understand the human body on a deeper level. It is just so fascinating! Chiropractic care has gone so far from “bone out of place / foot on the hose”-style nerve impingement, to a more advanced model of the VSC, to now a shift toward neuroscience and understanding the effects of an adjustment on the prefrontal cortex, sensorimotor integration, and neuroplasticity.  It is amazing the implications that our care can have, not just on the biomechanics, but on physiology and neurology of patients of all ages as well. I think because the care we offer impacts our base systems and has such far reaching implications, we get a little carried away with ourselves.

Anyway, I digress.  The fact is that research matters. It is part of the problem and it is part of the solution. Here is the Clif notes version of where we are at as a profession related to pediatric research:

  • We have a slew of case reports and case series.  These are meant to be the early explorers that give researchers a direction to start diving in deeper.  We have more than enough for the next 50 years of “this area warrants further investigation”.  The problem is, case reports and series do not carry much weight in and of themselves, even in bulk.  They matter and they are interesting, but they are not enough.
  • Everyone knows that double-blind, placebo-controlled RCTs (and meta-analyses of such) are the gold standard in research.  Those work great for pharmaceutical interventions, but it is difficult (if not impossible) to create a true “placebo” control for manual therapy and it is impossible to blind a practitioner as to whether or not they are providing the “true” physical treatment. That being said, it is possible to do RCTs in chiropractic care, it is just not easy to organize (or pay for).
    • Update: Since I wrote my first draft of this long meandering brain-dump, an extensive review of pediatric care has been published. I won’t get into it now, but here is the link4 if you want to check it out.
  • Research is expensive!  Chiropractic is not a wealthy profession. Large scale clinical trials comparing to no treatment and comparing to other common treatment alternatives would be ideal. These are REALLY expensive!

 

I want to highlight: there is not nothing. (Pardon my deliberate double negative.)  There is enough out there for us to conclude that our care is safe and that it warrants further investigation for specific conditions and populations.

  • Chiropractic care is safe for infants and children1,2,3,4.There are studies investigating this and the resultsof these studies overwhelmingly suggest that chiropractic care can be safely provided to even the youngest members of our society.  Adverse events in children receiving chiropractic care are very rare and usually involve short periods of muscle soreness that resolve on their own.  Serious adverse events associated with chiropractic care are extremely rare and tend to occur in children who have significant pre-existing health issues where the chiropractor did not modify their care appropriately when caring for the child.

The purpose of this paper is not for me to review all the research out there, but I do encourage you to actually look for yourself before you assume there is nothing. (For some perspective, when I completed my CACCP exam, it was 74 pages long and included over 85 references in my answer to just the first of thirteen questions/essays.)

Pioneers in Pediatric Research

I want to take this opportunity to highlight some people in our profession who are making headway in research.  We do have some pioneers.

  • Dr Katie Pohlman DC PhD at University of Alberta/Parker University whose research focus is on the safety of chiropractic care for children and who manages the SafetyNET reporting system. (She was also a big part of the systematic review I mentioned early.)
  • Dr Bernadette Murphy DC PhD at the University of Ontario whose research focus is to understand how altering afferent input from the spine and limbs affects sensorimotor integration and motor control. (This is important for pediatric care because it is often the primary focus of treatment in this population.)
  • Dr Joel Alcantara DC who is the research director for the ICPA and implementor of the ICPA’s Practice Based Research Network.
  • Dr Heidi Haavik DC PhD who is the research director for the Centre for Chiropractic Research in New Zealand. Dr Haavik is amazing. The research she does is elegant and focuses on the neuroscience & neuroplasticity of chiropractic care. She is also incredibly passionate about equipping chiropractors with the understanding of and capacity to explain the research.
  • Dr Joyce Miller DC PhD whose research and contribution to pediatric care “levelling up” are just brilliant. She is based out of the Anglo-European College of Chiropractic in England, at which she co-founded the University Feeding Clinic and she is involved with the University of Bournemouth’s Master’s Degree in MSK Health of the Pediatric Patient. Her published studies are elegantly designed. I had the opportunity to learn from her at The Kid’s Summit 2018 and I was thoroughly impressed (in case you can’t tell).

I’m sure there are many others out there who are diligently laying the foundation for practitioners like me to learn from.  If I missed you or someone you know doing something amazing in pediatric chiro research, I’m sorry.  Please reach out so I can learn from you too!

In the little picture: On a personal level

It is very easy to become caught up in all the things that should happen (and need to happen).  We need more research. We need more education. The association should do this. The college should do that.  Politics and policies. Money and time. This is all very important, but I am too impatient to wait.

Just like with environmental concerns, we do need change on a higher level. However, sometimes we go so caught up with the bigness of the problem that we become paralyzed, unable to act, and downright depressed. I am attempting both to not catastrophize and to implement positive action.

Here is my approach at creating positive momentum on a personal level and taking ownership over my piece of this:

  • I frickin study.  
    • I have been taking pediatric specialization courses (in and out of chiropractic) since I was in my first year of chiropractic college.  I took advantage of student discounts and living in the bay area to shove as much knowledge into my brain as I could. (I also started treating pregnant women, children, and infants while still in school at the teaching clinic and on-field events.) I shadowed countless pediatric practitioners up and down the west coast at every opportunity I could.
      • I also earned a Master of Science in Applied Clinical Nutrition where I focused all my capstone projects on pediatric neurodevelopmental conditions. Chemistry is important for kids too and there is so much more to pediatric chiropractic care than the adjustment!
    • Once finishing chiropractic college, I kept studying. I have spent a lot of time and money investing in pediatric postdoc education. And I still feel like I can never get enough.  In case you are wondering where to get started, here are some honourable mentions:
      • I would be remiss if I did not mention the ICPA.  Although our philosophical approaches and styles of practice often differ, I commend the ICPA in the work that they have done to increase to availability of pediatric courses. I have completed more than their base requirement of courses as well completed my CACCP. I am currently halfway through finishing up the DICCP.
      • The ACA Council on Chiropractic Pediatrics has grown a lot since I was in school.  I have had the opportunity to attend one weekend of seminars with them. It was at that symposium that I left all my Palmer West sports chiro friends behind and solidified my decision to focus on children. When I was in the states, their course series were difficult for me to attend logistically, so I have not done much with them, but they seem to have carried the torch well and I look forward to finding opportunities to connect with their courses in the future.
      • Dr Monika Buerger’s Intersect4Kids & Intersect4Life programs are a great place to learn more about neurodevelopmental disorders and the amalgamation of neurosensory integration, clinical nutrition, and chiropractic care.  Her courses changed my life.  At the first of hers I attended, I realized that I did not need to completely reinvent the wheel to combine all the forms of care I thought made sense together; she had already created the framework.
      • The Kids Summit.  This one gets a gold star.  Organized by Dr Dorte Bladt in Australia, not only does this program bring together a strong group of instructors, but all those instructors are paying their own way to get there. Why? Because 100% of the profits of this summit goes directly toward pediatric research (via Dr Haavik, mentioned earlier). It is a win win win win.  Incredible evidence-based pediatric education and further progression of pediatric research. I cannot say enough about TKS! They are going to be oversees for the next 2 years at least, but if you have a chance, GO!
      • Dr Claudia Anrig literally wrote the book. The textbook, that is, which if you do not own and you work with children, you should buy it. This is the only chiropractic textbook that I am aware of with the publishers Lippincott Williams & Wilkins.  That may seem meaningless to you, but it is big deal in academia.  Dr Anrig is also a lovely teacher and her First Adjustments program and are very good introduction to pediatric practice.
      • The Prague School of Rehab/DNS/Vojta. If you do not know what I am talking about, welcome to the rabbit hole. These guys are decades ahead of us when it comes to developmental kinesiology and rehab.  Their approach and methods are the foundation for many of the rehab-based systems that are popular in North America right now, but I prefer learning as close to the source as I can.  Their teaching complete pediatric and postnatal rehab and enhance my care in such a meaningful way.
      • The BCCA webinars.  The BCCA did a series of pediatric webinars last year on pediatric care.  I was really proud of them for identifying pediatrics as an area for which chiropractors required more support. Apparently, they were VERY well attended, meaning practitioners really are hungry for more education in this area. I’m sure you can find them archived somewhere.
      • Shadow. Seek out pediatric practitioners. Ask to follow them around for a day, go out for coffee, or delve into a more in-depth mentoring experience.  I think mentorship is becoming a lost art. If you are ever visiting the Okanagan, I would be happy to invite you into my clinic. (My patients are fairly accustomed to chiros and other professionals hanging out.)
      • Study. Do not underestimate the importance of your own reading. There are a few online and video courses out there too.
      • Do you really, really, really like to study?  There are a few post-professional programs out there too.
  • I contribute.
    • As practitioners in clinical practice, we can still contribute to the research.  I would love to actually publish my own research someday, but that pipe dream has been swept under the rug a few times with more pressing realities. Even so, there are way to contribute to the scientific base as a practicing chiro.
      • I have participated in 5 PBRNs with the ICPA.
      • I have participated in 2 safety studies with Dr. Katie Pohlman.
      • I have filled out every single survey and questionnaire that comes my way.
      • I contribute monthly to pediatric research through Dr Heidi Haavik.
        • & we have done a few little office fundraisers that contributed toward this as well.
  • I hold back.
    • I am VERY judicious in what I post online and how I communicate with the public and my patients.  I do not make ridiculous statements.  I do not market outside the efficacy claims policy.  I do not use fear tactics.  I do my best to approach my care in the most evidence-informed ways I know how. It is easy to be passionate about pregnancy and pediatrics. It is the best and I am stoked on it. I’m also a professional (and a really boring person).

To recap: I study, I contribute, and I exercise professional restraint.

I am a mom of a 3-year-old and wife to a very adventurous entrepreneur. I run a small multidisciplinary clinic that focused entirely on paediatric and perinatal care. I am obsessed with snowboarding and the great outdoors.  I do not have a lot time and I have zero cash flow under the mountain of student debt that it requires to get to this point.  What I am trying to say is that I have very little to work with in terms of time, money, and energy to devote to this dilemma.  But I can still do something.  I believe in a global community.  What I do and how I practice is going to impact my neighbours near and far. It is going to either pave the way or close the doors for those practitioners who are going to come after me.

My preference is to stay out of the political arena. I do not like being the centre of attention, ever.  But this is something that I do care deeply about and it certain has the potential to impact my career, seeing as I am a chiropractor who treats only children and pregnant women.

References & Resources

  1. Alcantara J, Ohm J, Kunz D. The safety and effectiveness of pediatric chiropractic: a survey of chiropractors and parents in a practice-based research network. Explore (NY). Sep-Oct 2009;5(5):290-295.
  2. Doyle MF. Is chiropractic paediatric care safe? A best evidence topic. Clinical Chiropractic. 9// 2011; 14(3):97-105.
  3. Prevost CP et al. Manual therapy for the pediatric population: a systematic review. BMC Complementary and Alternative Medicine. 2019; 19:60
  4. Todd AJ, Carroll MT, Robinson A, Mitchell EK. Adverse Events Due to Chiropractic and Other Manual Therapies for Infants and Children: A Review of the Literature. J Manipulative Physiol Ther. Oct 30 2014. https://bmccomplementalternmed.biomedcentral.com/articles/10.1186/s12906-019-2447-2

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