Children and chiropractic: what’s the harm?

In recent years, CAM use has increased dramatically, and children are not exempt from this use.¹–4 In particular, children with serious, chronic or recurrent illness have rates of CAM use that approach (in some cases, even exceed) 70%.⁵–12 There is a need to examine the safety and efficacy of CAM in children in a systematic unbiased way, with emphasis on the products and practices that are used most commonly or with greatest risk of harm or potential for benefit. As an example of CAM that enjoys widespread use with little systematic data collection regarding safety, let us consider children and chiropractic.

Many children are exposed to chiropractic for a variety of reasons, including health promotion, musculo-skeletal ailments and a wide array of other paediatric concerns, such as infantile colic, asthma, bed-wetting, etc.¹³–17 Some formal evaluations regarding the efficacy and effectiveness of this intervention have found conflicting results.¹³,¹⁸–21 For example, there is evidence from RCTs both for and against the use of chiropractic in infantile colic.¹³,¹⁸,¹⁹ Conflicting results are also reported by systematic reviews of adult chiropractic clinical trials.²⁰,²¹ While conflicting results are not unique to research involving chiropractic, more work needs to be done to clarify what benefit(s) chiropractic offers children.

Owing to scientific as well as political differences, there has been a historical ‘divide’ between some paediatric and chiropractic organisations. For example, in 1995, the Chairmen of the Departments of Pediatrics of Pediatric Hospitals in Canada issued a joint statement that refuted the role of chiropractic as preventative therapy or treatment for childhood illnesses, and called for suspension of public fiscal support for paediatric chiropractic treatment.²² Unfortunately no references were provided in this article, and in the ‘hierarchy’ of EBM, expert opinion does not fare well. The evidence does support the fact that parents take their children to chiropractors.¹⁶,¹⁷,²³,²⁴ If paediatricians have concerns,²⁵ they need to take an evidence-based approach. In the intervening 8 years there has been little effort to quantify the risks of chiropractic in children. Few case reports of paediatric adverse events related to chiropractic have been published,²⁶–28 and no systematic reviews or prospective studies to quantify harm have yet been done.

In that same time period, case reports of adverse events related to chiropractic have led to more rigorous studies to examine this issue in adults. For example, a review of the literature on complications of spinal manipulation, which evaluated relevant case reports, surveys and review articles, identified 295 complications, yielding estimates of vertebrobasilar accidents from 1 in 20 000 patients to 1 per 1 million cervical manipulations, and cauda equina syndrome to be less than 1 per 1 million treatments.²⁹ A different approach, using a nested case-control study, matched 582 patients who had experienced vertebrobasilar accidents with control subjects (i.e. non-patients) who did not have a history of stroke.³⁰ Patients younger than 45 years who had experienced a vertebrobasilar accident were five times more likely to have had more than three cervical treatments in the preceding month.³⁰ This study also found approximately 1.3 cases of vertebrobasilar accidents within 1 week of treatment for every 100 000 chiropractic patients below the age of 45 years.³⁰ Clearly, if there is no potential for benefit, then it is unreasonable to undertake a potential risk of harm. Most instances are not so clear cut, and the only way to evaluate the risk:benefit ratio is with more data. To date, there have been no such systematic reviews that evaluate adverse events with respect to chiropractic specifically in children. Until such data are collected and synthesised, arguments for or against the safety of chiropractic in children are based on emotion and prejudice, and are inadequate to counsel patients.

Of course, ‘adverse’ events may be interpreted narrowly, such as physical harm, or broadly, such as cost, opportunity cost (time spent when an effective known therapy was also available but not pursued), and effect on overall health (e.g. decision made not to immunise child based on chiropractor’s advice, etc.). Broad interpretation is especially relevant since there is some evidence that some chiropractic care may be inconsistent with medical guidelines,²³ and that chiropractors may give advice on diet, immunisations and general health.²³,³¹,³² While a broad interpretation of harm may be clinically relevant, it is much more difficult to quantify. Even a narrow interpretation of harm with respect to chiropractic has yet to be quantified in children.

While the RCT may be the ‘gold’ standard to evaluate the efficacy of some health interventions, it is acknowledged that it is not the ideal tool to collect safety data. Indeed, safety data are rarely even reported in many RCTs or systematic reviews.³³,³⁴ Rather, population-based prospective data collection is a much more powerful tool for assessing potential harm. Similar efforts to assess the safety of acupuncture have led to several reassuring reports that rates of serious adverse events are in fact quite low.³⁵,³⁶ Such population-based studies should not be difficult to do, given that many children are seen by chiropractors, and many chiropractors see children.¹⁶,¹⁷,²⁴ Once the numerator (number of adverse events) and denominator (number of treatments) are known, potential adverse events with chiropractic can be put into context, relative to risks associated with other therapies, such as adverse events due to medications or surgery. The risk:benefit ratio can only be considered if data on both efficacy and harm are collected; at present, in children, neither is substantive. Ultimately, these data are needed so that paediatric patients, their families and their healthcare providers can better evaluate ‘what’s the harm’ with respect to children and chiropractic.

References

1. Eisenberg D, Kessler R, Foster C et al. Unconventional medicine in the United States: prevalence, costs, and patterns of use. N Engl J Med 1993; 328: 246–52. [Abstract]
2. Eisenberg DM, Davis RB, Ettner SL et al. Trends in alternative medicine use in the United States, 1990–1997: results of a follow-up national survey. JAMA 1998; 280: 1569–75. [Abstract]
3. Millar WJ. Use of alternative health care practitioners by Canadians. Can J Public Health 1997; 88: 154–8.
4. Spigelblatt L, Saine-Ammara G, Pless IB et al. The use of alternative medicine by children. Pediatrics 1994; 94: 811–14.
5. Fernandez CV, Stutzer CA, MacWilliam L, Fryer C. Alternative and complementary therapy use in pediatric oncology patients in British Columbia: prevalence and reasons for use and nonuse. J Clin Oncol 1998; 16: 1279–86.
6. Northcott H, Bachynsky J. Concurrent utilization of chiropractic, prescription medicines, non-prescription medicines and alternative health care. Soc Sci Med 1993; 37: 431–5. [Abstract]
7. Simpson N, Pearce A, Finlay F, Lenton S. The use of complementary medicine in paediatric outpatient clinics. Ambul Child Health 1998; 3: 351–6.
8. Ottolini M, Hamburger E, Loprieto J et al. Alternative Medicine Use Among Children in the Washington DC Area. San Francisco, CA: Paediatric Academic Societies, 1999.
9. Southwood TR, Malleson PN, Roberts-Thomson PJ, Mahy M. Unconventional remedies used for patients with juvenile arthritis. Pediatrics 1990; 85: 150–4.
10. Stern RC, Canda ER, Doershuk CF. Use of nonmedical treatment by cystic fibrosis patients. J Adolesc Health Care 1992; 13: 612–15. [Abstract]
11. Sawyer MG, Gannoni AF, Toogood IR et al. The use of alternative therapies by children with cancer. Med J Aust 1994; 160: 320–2.
12. Friedman T, Slayton W, Allen L et al. Use of alternative therapies for children with cancer. Pediatrics 1997; 100(6): El. Available at http://pediatrics.aappublications.org/cgi/content/full/100/6/el
13. Wiberg JMM, Nordsteen J, Nilsson N. The short-term effect of spinal manipulation in the treatment of infantile colic: a randomized controlled trial with a blinded observer. J Manipulative Physiol Ther 1999; 22: 517–22. [Abstract]
14. Balon J, Aker PD, Crowther ER et al. A comparison of active and simulated chiropractic manipulation as adjunctive therapy for childhood asthma. N Engl J Med 1998; 339: 1013–20. [Abstract]
15. Reed WR, Beavers S, Reddy SK, Kern G. Chiropractic management of primary nocturnal enuresis. J Manipulative Physiol Ther 1994; 17: 596–600.
16. Munck LK, Hoffmann H, Nielsen AA. Treatment of infants in the first year of life by chiropractors: incidence and reasons for seeking treatment. Ugeskr Laeger 1988; 150: 1841–4.
17. Jensen KM, Rasmussen LR. Children in Danish chiropractic clinics: a descriptive questionnaire study. Eur J Chiropractic 1989; 37: 117–24.
18. Mertz JA, Kemper K, Lee AC. Chiropractic care for children can help. Arch Pediatr Adolesc Med 2000; 154: 1062–3.
19. Olafsdottir E, Forshei S, Fluge G, Markestad T. Randomized controlled trial of infantile colic treated with chiropractic spinal manipulation. Arch Dis Child 2001; 84: 138–41. [Abstract]
20. Ernst E, Harkness E. Spinal manipulation: a systematic review of sham-controlled, double-blind, randomized clinical trials. J Pain Symptom Manage 2001; 24: 879–89.
21. Assendelft WJJ, Koes BW, Knipschild PG, Bouter LM. The relationship between methodological quality and conclusions in reviews of spinal manipulation. JAMA 1995; 274: 1942–8. [Abstract]
22. Children and chiropractors. A Statement by the Chairmen of the Departments of Pediatrics of Pediatric Hospitals in Canada. Can J Pediatr 1995; 2: 5–6.
23. Lee AC, Li DH, Kemper KJ. Chiropractic care for children. Arch Pediatr Adolesc Med 2000; 154: 401–7.
24. Verhoef M. Survey of Canadian chiropractors’ involvement in the treatments of patients under the age of 18. J Can Chiropr Assoc 1999; 43: 50–7.
25. Waimer S, Govender T. Pediatric chiropractic. Paediatr Child Health 2002; 7: 114–15.
26. Shafrir Y, Kaufman BA. Quadriplegia after chiropractic manipulation in an infant with congenital torticollis caused by a spinal cord astrocytoma. J Pediatr 1992; 120: 266–9. [Abstract]
27. Nickerson HJ, Silberman TL, Theye FW, Rushing DA. Chiropractic manipulation in children. J Pediatr 1992; 12: 172.
28. Turow VD. Chiropractic for children. Arch Pediatr Adolesc Med 1997; 151: 527–8.
29. Assendelft WJJ, Bouter LM, Knipschild PG. Complications of spinal manipulation: a comprehensive review of the literature. J Fam Prac 1996; 42: 475–80.
30. Rothwell DM, Bondy SJ, Williams SJ. Chiropractic manipulation and stroke: a population-based case-control study. Stroke 2001; 32: 1054–60.
31. Hawk C, Long CR, Boulanger KT. Prevalence of non-musculoskeletal complaints in chiropractic practice: report from a practice-based research program. J Manipulative Physiol Ther 2001; 24: 157–69.
32. Hawk C, Byrd L, Jansen RD, Long CR. Use of complementary health practices among chiropractors in the United States: a survey. Altern Ther Health Med 1999; 5: 56–62.
33. Moher D, Sampson M, Campbell K et al. Assessing the quality of reports of randomized trials in paediatric complementary and alternative medicine. BMC Paediatrics 2002; 2: 2.
34. Ernst E, Pittler MH. Systematic reviews neglect safety issues. Arch Intern Med 2001; 161: 125–6. [Abstract]
35. White A, Hayhoe S, Hart A, Ernst E. Adverse events following acupuncture: prospective survey of 32 000 consultations with doctors and physiotherapists. BMJ 2001; 323: 485–6. [Abstract]
36. MacPherson H, Thomas K, Walters S, Fitter M. The York acupuncture safety study: prospective survey of 34 000 treatments by traditional acupuncturists. BMJ 2001; 323: 486–7. [Abstract]