MD, PhD, FMedSci, FRSB, FRCP, FRCPEd

Some of you will remember the saga of the British Chiropractic Association suing my friend and co-author Simon Singh (eventually losing the case, lots of money and all respect). One of the ‘hot potatoes’ in this case was the question whether chiropractic is effective for infant colic. This question is settled, I thought: IT HAS NOT BEEN SHOWN TO WORK BETTER THAN A PLACEBO.

Yet manipulators have not forgotten the defeat and are still plotting, it seems, to overturn it. Hence a new systematic review assessed the effect of manual therapy interventions for healthy but unsettled, distressed and excessively crying infants.

The authors reviewed published peer-reviewed primary research articles in the last 26 years from nine databases (Medline Ovid, Embase, Web of Science, Physiotherapy Evidence Database, Osteopathic Medicine Digital Repository , Cochrane (all databases), Index of Chiropractic Literature, Open Access Theses and Dissertations and Cumulative Index to Nursing and Allied Health Literature). The inclusion criteria were: manual therapy (by regulated or registered professionals) of unsettled, distressed and excessively crying infants who were otherwise healthy and treated in a primary care setting. Outcomes of interest were: crying, feeding, sleep, parent-child relations, parent experience/satisfaction and parent-reported global change. The authors included the following types of peer-reviewed studies in our search: RCTs, prospective cohort studies, observational studies, case–control studies, case series, questionnaire surveys and qualitative studies.

Nineteen studies were selected for full review: seven randomised controlled trials, seven case series, three cohort studies, one service evaluation study and one qualitative study. Only 5 studies were rated as high quality: four RCTs (low risk of bias) and a qualitative study.

The authors found moderate strength evidence for the effectiveness of manual therapy on: reduction in crying time (favourable: -1.27 hours per day (95% CI -2.19 to -0.36)), sleep (inconclusive), parent-child relations (inconclusive) and global improvement (no effect).

Reduction in crying: RCTs mean difference.

The risk of reported adverse events was low (only 8 studies mentioned adverse effects at all, meaning that the rest were in breach of research and publication ethics): seven non-serious events per 1000 infants exposed to manual therapy (n=1308) and 110 per 1000 in those not exposed.

The authors concluded that some small benefits were found, but whether these are meaningful to parents remains unclear as does the mechanisms of action. Manual therapy appears relatively safe.

For several reasons, I find this review, although technically sound, quite odd.

Why review uncontrolled data when RCTs are available?

How can a qualitative study be rated as high quality for assessing the effectiveness of a therapy?

How can the authors categorically conclude that there were benefits when there were only 4 RCTs of high quality?

Why do they not explain the implications of none of the RCTs being placebo-controlled?

How can anyone pool the results of all types of manual therapies which, as most of us know, are highly diverse?

How can the authors conclude about the safety of manual therapies when most trials failed to report on this issue?

Why do they not point out that this is unethical?

My greatest general concern about this review is the overt lack of critical input. A systematic review is not a means of promoting an intervention but of critically assessing its value. This void of critical thinking is palpable throughout the paper. In the discussion section, for instance, the authors state that “previous systematic reviews from 2012 and 2014 concluded there was favourable but inconclusive and weak evidence for manual therapy for infantile colic. They mention two reviews to back up this claim. They conveniently forget my own review of 2009 (the first on this subject). Why? Perhaps because it did not fit their preconceived ideas? Here is my abstract:

Some chiropractors claim that spinal manipulation is an effective treatment for infant colic. This systematic review was aimed at evaluating the evidence for this claim. Four databases were searched and three randomised clinical trials met all the inclusion criteria. The totality of this evidence fails to demonstrate the effectiveness of this treatment. It is concluded that the above claim is not based on convincing data from rigorous clinical trials.

Towards the end of their paper, the authors state that “this was a comprehensive and rigorously conducted review…” I beg to differ; it turned out to be uncritical and biased, in my view. And at the very end of the article, we learn a possible reason for this phenomenon: “CM had financial support from the National Council for Osteopathic Research from crowd-funded donations.”

7 Responses to Manual therapies for infant colic? A very sore point in the history of chiropractic

  • Colic hold is a more or less effective manual manipulation that might help to release gas and for defecation in babies because babies try to build up pressure to release gas or faeces by crying (they cannot hold their breath) but they have problems to direct the pressure the right way down to the anus the first or early months.

    If any other manual therapy is applied like spinal manipulation or craniosacral or else the results of such studies could only be taken for real in infant colic if touching a baby’s stomach or belly is not allowed at all during such “therapeutic” procedures or BEFORE or AFTER at all fot the WHOLE time of the study.

    Who ever could control this at all that the stomach/belly is NEVER EVER touched for ANY REASON as long as a baby/child is part of such a study about infant colic. If not you might proof even that a prayer might help 🙂

    I mean that’s rediculous… If you know how to hold a baby in or even before colics you might manipulate any study…

  • Unfortunately this review adds little to the literature because rather than seeking to test IF manual therapy is effective for infantile colic they clearly set out to try and show that it does. An interesting insight into the approach can be seen from the July 2016 edition of the National Council for Osteopathic Research (https://www.ncor.org.uk/wp-content/uploads/2016/07/NCOR_news-2016-07.pdf). They say “Some papers are proving very hard to locate, unfortunately, so watch out for our appeals on social media. If you have some old osteopathic or chiropractic magazines in the attic, we may ask you to dust them off and search for some articles for us!” This indicates that they are trying very hard to look for papers that are not readily available or recent, probably in the hope that they will show some positive results. Unfortunately, like most alternative medicine practitioners, osteopaths are unable or unwilling to conduct research in a professional unbiased manner and instead seek to use research to justify and promote their treatments. Papers like this should therefore be treated with a great deal of scepticism or simply ignored.

    • “Papers like this should therefore be treated with a great deal of scepticism or simply ignored.”
      I entirely agree!
      The trouble is though that such papers pollute the medical literature and give false-positive impressions to the less than critical observer.

      • I agree, and I commend you for tackling this issue. In this particular case, I suspect a major motivator for this paper is to try and tackle the advertising restrictions placed on osteopaths and chiropractors by the Advertising Standards Authority. Osteopaths and chiropractors want to be able to advertise that they can treat colic even though their “treatments” are completely ineffective. I just hope that the ASA can see through this heavily biased “research”

  • Here is text copy of a popular, widespread internet/Facebook-post spreading through every corner of the US….it has a weeks-old baby’s back with hands on it with the caption: “Chiropractic adjustments. 95% have misalignments from birth. Chiropractic is shown to relax muscle tension, help sleep and reduce colic symptoms and help nursing”.
    Then the considerate poster adds their own 2-cents:
    “THE BIRTH PROCESS CAN BE VERY TRAUMATIC TO YOUR CHILD. It can be especially dangerous if the child is breech or if forceps or vacuum extraction is performed.
    Misalignment to the upper neck can lead to ear infections, sinus problems, tonsil and adenoid issues as well as ADD/ADHD and headaches. This is why it’s extremely important to have your newborn child checked by our office for “Subluxation” at Birth.
    All of my daughters were checked for vertebral subluxation immediately, which is why they’re so healthy today.
    If your child is struggling with health issues please contact our office today for a FREE consultation.
    Blessings!”
    We all know that “reform” of a fraudulent, avarice, entrepreneurial-pseudoscience is mission IMPOSSIBLE.

    • .. The advertisement of “osteopaths” (European/Commonwealth osteopathic manipulators is like this:
      Come to us because birth is always traumatic.
      For sectio because babies have not received enough pressure
      For normal delivery because babies had received too much pressure
      For gas formations because the vagus nerve might be under pressure
      For plagiocepalus because of asymmetric pressure there must be manual treatment to give back a good shaped skull.
      So there is no reason for NOT to visit an osteopath …
      Isn’t it a collective dellusion an idiotic madness ???

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