MD, PhD, MAE, FMedSci, FRSB, FRCP, FRCPEd.

The Foundation for Vertebral Subluxation has a ‘clinical practice guideline/best practices project’ that would search, gather, compile and review the scientific literature going as far back as January 1998. Their new Chapter on the chiropractic care of children was peer-reviewed and approved by 196 chiropractors from several countries and included chiropractors specializing in pediatric and maternal care such as Diplomates and others certified in such care. The Best Practices document, developed through the Foundation’s Best Practices Initiative includes a Recommendation statement as follows:

Since vertebral subluxation may affect individuals at any age, chiropractic care may be indicated at any time after birth. As with any age group, however, care must be taken to select adjustment methods most appropriate to the patient’s stage of development and overall spinal integrity. Parental education by the chiropractor concerning the importance of evaluating children for the presence of vertebral subluxation is encouraged as are public health initiatives geared toward screening of children for vertebral subluxation beginning at birth.

I am afraid there may be some errors in the new document. Allow me therefore to post a corrected version:

Since vertebral subluxations do not exist, they cannot affect individuals regardless of age. Chiropractic adjustments are thus not indicated at any time after birth. Parental education by the chiropractor concerning the importance of evaluating children for the presence of vertebral subluxation is discouraged as are public health initiatives geared toward screening of children for vertebral subluxation beginning at birth.

Or, as an American neurologist once put it so much more succinctly:

Don’t let the buggers touch your neck!

56 Responses to Best Practices for the Chiropractic Care of Children

  • An Australian may say: don’t let the buggers bugger your neck.

  • Chiropractors need to have unfettered access to children under 12 years of age so they can examine and diagnose the need for appropriate manipulative and rehabilitative treatment. May I present a recently published and well-designed case report to support my position. https://www.jstage.jst.go.jp/article/jpts/34/1/34_2021-127/_article/-char/en?fbclid=IwAR3VxK-L46JtUD3SmSwipvWod0wpDCrPBb2Eh3XYsXPPOV3cgdzAuKI5McQ

    • Thank you for providing a CASE REPORT thus demonstrating that you have no real evidence.

      • Edzard, As you very well know, a well-designed case report published and supported in a journal not related to chiropractic very often reflects the same results from an RCT. It also must be reported that childhood injuries from chiropractic management are few and far between. Registered chiropractors have every right to attend to patients of all ages like all other registered healthcare practitioners. Trust I am clear.

        • “As you very well know…”
          No, I don’t
          WHERE DO YOU HAVE THIS IDIOCY FROM?

        • I think we are arguing that whatever the law in a given country might currently be, it ought to be changed to prevent ‘practitioners’ subjecting anyone, infant or adult, to fake practices based on unfounded ideas (such as subluxation). It does seem especially worrying that babies are subjected to this dangerous charlatanry.

        • Mr Epstein,

          As you very well know, a well-designed case report published and supported in a journal not related to chiropractic very often reflects the same results from an RCT.

          And very often it doesn’t. For this reason it is unsafe practice to base any form of treatment on a case report or indeed on the experience of a single practitioner.

    • @Michael Epstein
      You really need to stop citing crap from Deed Harrison ™. Turning up to multidiciplinary conferences and handing out copies of his poor quality studies to world class researchers has also gone down like a lead balloon. They do actually read them, were unimpressed with his research and noted you doing the same at other conferences.
      I recommend you buy this book by Trisha Greenhalgh – “How to Read a Paper”.
      https://www.booktopia.com.au/how-to-read-a-paper-trisha-greenhalgh/book/9781119484745.html
      Then actually critically read Deed’s research ™.
      @Edzard Ernst
      Citing Matthew McCoy and the Foundation for Vertical Submarines.
      You do like picking the low hanging fruit(cakes).

  • To me, the chiropractic treatment of the babies borders on child abuse and intentional bodily harm.

  • Ghastly. Couching a falsehood in a quasi-medical linguistic ‘register’ does not turn it into truth. But sadly some, including ‘practitioners’ find it convincing.

  • Don’t let the buggers touch your neck!

    I’d say that especially for children, this guiding principle could be further abbreviated:

    Don’t let the buggers touch you!

  • This pretty much informs one as to their (FVS) mindset.

    “Dedicated to the Founding Principles & Tenets of the Chiropractic Profession.”

    These folks are often referred to as Principled Chiropractors and are at odds with those chiropractors who are more science-based…as some here refer to this as a Chiro-War.

    Most papers on the topic put these Principled Chiropractors around 20-25% of the profession. A minority of the profession but yet they are very vocal. Their position on pediatrics and chiropractic is based primarily on “philosophy”, not science.

    This topic recently came up in one of my groups (regarding Webster Technique). My response:

    “I see an opportunity for someone to create an evidence informed class/certificate that would appeal to pediatricians.”

    Thus, the general question is: is there a need/place for manual therapy within the pediatric population? However, the question is beyond the intentions of Ernst’s blog.

    • Principled? Surely it’s a problem if they are adhering to a false ‘principle’ – subluxation?

    • “The Webster Technique is a method within the field of chiropractic that proponents claim can assist in rotating a breech baby. The scientific studies on this technique are minimal in number and weak in conclusion, such that some chiropractic colleges and regulatory groups disallow their members from advertising the technique at all.”
      https://en.m.wikipedia.org/wiki/Webster_Technique

      See also:
      https://edzardernst.com/2016/09/delivery-of-chiropractic-therapies-to-the-unborn-child/

      • “The scientific studies on this (Webster) technique are minimal in number and weak in conclusion…”

        Agreed, which goes back to my comment on a program that would appeal to pediatricians (assuming it is shown to be valid). Better evidence is needed.

        • “Better evidence is needed.”

          Because, of course, 36 years isn’t nearly long enough to generate the better evidence.

          QUOTE
          The Webster Technique first appeared in 1986 as developed by its namesake, Larry Webster, D.C. Webster was the founder of the International Chiropractic Pediatric Association (ICPA). This organization strives to “promote and defend” the use of chiropractic for children and pregnant women.[1][2]
          https://en.m.wikipedia.org/wiki/Webster_Technique#Origin

          • “Because, of course, 36 years isn’t nearly long enough to generate the better evidence.”

            I am not defending the lack of better evidence.

          • “I am not defending the lack of better evidence.” [for the Webster Technique]

            Above, you quoted yourself saying:
            “I see an opportunity for someone to create an evidence informed class/certificate that would appeal to pediatricians.”

            So, you aren’t defending the lack of better evidence; but you are promoting: an evidence informed [sic] class/certificate that would appeal to pediatricians.

            Your hubris is utterly disgraceful, but I’m glad you’ve demonstrated it so clearly (yet again).

            No wonder you hide behind various pseudonyms.

          • You do know that in order to appeal to pediatricians one would need better research?

            You do know that research is part of being evidence informed?

            “An evidence-informed approach to practice can be defined as the integration of research evidence alongside practitioner expertise and the people experiencing the practice (e.g. child and parent using a service or program)3,7” Australian Institute of Family Services

            You’re barking up the wrong tree.

          • Were you and your group in Australia at the time? If not then quoting from the Australian Institute of Family Services is misdirection. If you were in Australia then what relevance does your comment have to me, the rest of the world, and the The Foundation for Vertebral Subluxation project (other than a pathetic attempt at deflection; clutching at straws; a red herring).

            This topic recently came up in one of my groups (regarding Webster Technique). My response:

            “I see an opportunity for someone to create an evidence informed class/certificate that would appeal to pediatricians.”

          • Pete, the only way one can have an objection to what I wrote is if one does not want a pediatric program within chiropractic that is evidence-informed.

            I think you are one of those: damned if they do, damned if they don’t. They waste my time. Take care.

          • I’m just letting you clearly demonstrate your promotion of quackery. The following is information for the readers; a reply from you, “DC”, isn’t wanted so don’t waste your time writing one.

            Delivery of Chiropractic Therapies to the Unborn Child
            https://edzardernst.com/2016/09/delivery-of-chiropractic-therapies-to-the-unborn-child/
            QUOTE
            The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) is aware that some chiropractors are advertising and attempting to turn breech babies in utero using the “Webster Technique”.

            On 7 March 2016, the Chiropractic Board of Australia released the following statement in relation to chiropractic care of pregnant women and their unborn child:

            Care of pregnant patients

            Chiropractors are not trained to apply any direct treatment to an unborn child and should not deliver any treatment to the unborn child. Chiropractic care must not be represented or provided as treatment to the unborn child as an obstetric breech correction technique.

            RANZCOG supports the Chiropractic Board of Australia in its clear position that chiropractic care must not be represented or provided as a treatment to the unborn child as an obstetric breech correction technique. Chiropractors should not be using the “Webster Technique” or any other inappropriate breech correction technique to facilitate breech version as there is insufficient scientific evidence to support this practice.

            In addition, RANZCOG does not support chiropractors treating pregnant women to reduce their risk of caesarean delivery. There is insufficient evidence to make any claims to consumers regarding the benefits of chiropractic treatment to reduce the risk of caesarean delivery. We commend the Chiropractic Board on their statement that:

            “Advertisers must ensure that any statements and claims made in relation to chiropractic care are not false, misleading or deceptive or create an unreasonable expectation of beneficial treatment.”
            END of QUOTE

            The Webster Technique: An Offshoot of “Chiropractic Pediatrics”, Samuel Homola, DC
            https://quackwatch.org/chiropractic/dd/webster/
            QUOTE
            Many chiropractors are “adjusting” the spines of pregnant women to “assure normal delivery” and to prevent breech birth caused by “intrauterine constraint.” This dubious treatment — known as the Webster Technique — is based on the equally dubious theory that vertebral subluxations can cause malfunction in the uterus by putting pressure on spinal nerves. Chiropractors who advocate the Webster Technique, claim:

            • Failure to prevent sacral and pelvic subluxations can result in abnormal positioning of the baby in the uterus.
            • Babies can be turned from a breech position to a normal vertex (head down) position simply by adjusting the sacrum.

            These contentions are not merely nonsensical. Reliance on the Webster Technique during the final weeks of pregnancy can endanger both the mother and the child.

            Chiropractic “Pediatrics”

            Many chiropractors who use the Webster Technique identify themselves as “chiropractic pediatricians,” a title they are not qualified to claim. Most chiropractic students receive about 15 hours of classroom instruction in obstetrics and gynecology and 15 hours in pediatrics [1], certainly not enough training to warrant treating patients in these fields.

            With so little training and clinical experience in treating pregnant women and their babies, and with a limited treatment method that consists primarily of spinal manipulation, I cannot imagine how chiropractors can manage pregnancies or treat newborn babies and children. Subluxation-based chiropractors who offer such treatment feel that a spinal adjustment is adequate treatment for most ailments. Claiming that the adjustments “remove pressure on the spinal cord and the spinal nerves,” such chiropractors manipulate the expectant mother’s spine during pregnancy and then manipulate the spine of the newborn infant, a truly despicable practice.

            Before or during labor for example, if the cervix dilates sufficiently, a breech presentation poses the risk that if the “water bag” breaks, the umbilical cord can squirt into the vagina and create a life-threatening emergency. If labor begins and progresses to the point of delivery, a vaginally-delivered breech baby has a higher risk of sustaining serious neurological injury. In some of these cases, efforts to turn the baby through the abdominal wall are warranted. But even in the best of hands, simultaneous ultrasound monitoring is necessary, but the the fetus may still become entangled in its umbilical cord, necessitating an immediate cesarean delivery. Chiropractors do not have access to and are not trained in obstetric ultrasound and are not qualified to immediately deliver a baby if necessary. [my emphasis]
            END of QUOTE

            See also
            https://en.m.wikipedia.org/wiki/Webster_Technique#Regulations

          • DC: Better evidence is needed.

            Pete: I’m just letting you clearly demonstrate your promotion of quackery.

            Calling for better evidence is the promotion of quackery?

            Do you think before you comment?

  • RPGNo1 : To me, the chiropractic treatment of the babies borders on child abuse and intentional bodily harm.”

    Would that not depend on the condition and treatment? Some PTs don’t seem to have an issue with treating infants. Example

    https://www.nspt4kids.com/parenting/common-physical-therapy-red-flags-pediatrician-well-visits-babys-first-year/

    Is this also to be considered child abuse?

  • You say that chiropractic adjustments are ‘not indicated at any time after birth’

    So are you supportive of fetal chiropractic? 😉

    • It may be helpful to state that there is no such thing as a chiropractic adjustment. Instead, it is an adjustment by a chiropractor (or PT or DO or MD).

      • but is that really true. The adjustments by an osteopath or a PT are based on different theories and the techniques are different.

        • To my knowledge none of the professions have exclusive rights to any specific type of adjustment. We can do all of them just as they can. Thus, there is no such thing as a chiropractic adjustment.

          • Do any other ‘practitioners’ carry out manipulations based on the doctrine of subluxations?

          • DC a question i often ask is ” are there any alternative health practices that you believe are useless and belong in the dust bin of history” (Usually the reply from alternative health practitioners is silence.) Admittedly you may consider yourself a Health practitioner and think there is nothing alternative about chiropractic) at my workplace a chiropractor convinced our HR department to invite him to give a health lecture to employees. At the lecture he advocated neck adjustments for childhood ear infections, and with applied kinesiology fooled some in the audience that having a turned on cell phone in one’s hand made the arm weaker. Now applied kinesiology has been debunked when the subject and evaluator are blinded and neck nerves do not go to the middle ear so neck adjustments cannot release pressure to those nerves….anything in the chiropractic or non chiropractic medical world that should be abandoned?
            Reiki? Healing touch? Homeopathy, Cranial sacral therapy to release blockages in cerebral spinal fluid?…

          • “Chiropractic adjustment tools (CATs) from JTECH Medical are the most affordable chiropractic adjusting instruments available.”
            https://www.jtechmedical.com/products/adjusting-tools

            The following document uses the term chiropractic adjustment 11 times, one example shown:

            “THE COUNCIL ON CHIROPRACTIC EDUCATION

            CCE Accreditation Standards

            January 2018

            META-COMPETENCY 7 – CHIROPRACTIC ADJUSTMENT/MANIPULATION
            Doctors of chiropractic employ the adjustment/manipulation to address joint and neurophysiologic dysfunction. The adjustment/manipulation is a precise procedure requiring the discrimination and identification of dysfunction, interpretation and application of clinical knowledge; and the use of cognitive and psychomotor skills.”
            https://www.cce-usa.org/uploads/1/0/6/5/106500339/2018_cce_accreditation_standards.pdf

          • John: DC a question i often ask is ”are there any alternative health practices that you believe are useless and belong in the dust bin of history”

            If the scientific process shows that the practice is useless, sure. That holds true if the practice is alternative or not.

            Now do I think there are some alt med practices that are a waste of time and money to research and should be abandoned based on logic and reasoning. Sure.

            Example: Buddhist healing spells

          • “If the scientific process shows that the practice is useless, sure.”
            And I had always thought that
            1) proving a negative was impossible
            2) to be credible, a practice needs to be demonstrably effective

          • EE And I had always thought that
            1) proving a negative was impossible

            Where did I write that it was proving a negative?

            Medical research looks to see if some current practices actually have any benefit. If not, it is (or should be) discarded.

          • John: and neck nerves do not go to the middle ear so neck adjustments cannot release pressure to those nerves

            If there is a mechanism it may be different from what those chiropractors think.

            Example:

            “Eustachian tube mucosa was found to be sympathetically innervated by fibres originating in the ipsilateral superior and middle cervical ganglia,…”

            https://www.tandfonline.com/doi/abs/10.3109/00016488809097007

          • DC I stand corrected with regards to neck adjustments not effecting nerves going to the middle ears.
            Your link shows some fibers from a neck ganglia go to the eustachian tube. So one who accepts chiropractic theory that subtle pressure on nerves in the neck might effect nerves to the ganglia listed in the article and by them the eustachian tube nerves. And then the eustachian tube would be effected..ect. There is plausibility we believe adjustment help
            subluxations and they commonly increases susceptibility to ear infections.

            I am disappointed you did not try very hard to list bogus treatments. Surely you do not believe I can treat your ills by from the comfort of my keyboard with Reiki. Surely you do not think you can treat my itching rash with homeopathic pills made from poison oak diluted till there are no atoms of poison oak in the pill.

            This whole subluxation thing for people not recently in an accident seems bogus to me.
            Has this test ever been done?
            1 Put whatever oil might be used on the backs of 100 people.
            2. Adjust 50.
            3. Then bring in 30 chiropractors to check them out and tell who has been adjusted and who has not.

            What do you think the result would be?
            I think chiropractors would fail.

          • John: So one who accepts chiropractic theory that subtle pressure on nerves in the neck might effect nerves to the ganglia listed in the article and by them the Eustachian tube nerves.

            There are means to influence the sympathetics other than “subtle pressure.”.But yes, one concept is that a somatic dysfunction in the cervical spine can influence the associated sympathetics which would thereby have an influence on Eustachian tube function which could play a role in some ear infections.

            John: I am disappointed you did not try very hard to list bogus treatments.

            I suspect if you made a list of what you think are bogus treatments that I would agree with most or all of them.

            John: This whole subluxation thing for people not recently in an accident seems bogus to me.

            Just think of a chiropractic subluxation as a paraspinal muscle spasm.

            John: What do you think the result would be?
            I think chiropractors would fail.

            Studies have been done to look at the agreement between chiropractors (osteopaths have done similar research) regarding the location of areas to be adjusted. Interestingly enough there isn’t good agreement and yet other research indicates that it may not change the results. That’s probably due to the function and innervation pattern of the deep paraspinal muscles….they tend to work in sets of 3s and/or 5s.

          • John Smith

            I stand corrected with regards to neck adjustments not effecting nerves going to the middle ears.

            DC’s claim was only about innervation of the Eustachian tube mucosa. From my bit of Googling, it appears that most of the inner ear innervation is by cranial nerves, principally the vagus and trigeminal. Cranial nerves do not emerge from the spine.

          • Prl: Cranial nerves do not emerge from the spine.

            True, which is why they are called cranial nerves and not spinal nerves.

            Prl: it appears that most of the inner ear innervation is by cranial nerves, principally the vagus and trigeminal.

            You may find this early work of interest.

            “On the basis of a larger serie of degeneration studies on cats it appears that the postganglionic fibres of this bloodvessel independent system originate in the superior cervical ganglion and reach the inner ear either via tympanic plexus — facial nerve — internal acoustic meatus or via auricular branch of X — facial nerve and internal acoustic meatus.” https://link.springer.com/article/10.1007/BF00440938

            And this:

            “Hedger and Webber (1976) showed that the rat SCG has branches connected to the 9th, 10th, 11th, and 12th cranial nerves and the 1st, 2nd, 3rd, and 4th cervical spinal nerves.” https://anatomypubs.onlinelibrary.wiley.com/doi/full/10.1002/ar.23953

            And this:

            “The vestibular sympathetics originated in the ipsilateral superior cervical ganglion and entered the internal auditory meatus along the labyrinthine artery.” https://www.tandfonline.com/doi/abs/10.3109/00016488909127496?journalCode=ioto20

            “Hence, this evidence leads to the current theory that cervical vertigo results from abnormal input into the vestibular nuclei from the proprioceptors of the upper cervical region.” See also Table 1. https://www.painphysicianjournal.com/current/pdf?article=MjM3NQ%3D%3D&journal=89

            Etc.

            Of course, the above comparative neuroanatomy studies have their limitations. Regardless, an intriguing area of study but it deviates from the original topic.

          • DC,

            I have certainly seen Horner’s syndrome following neck surgery (drooping eyelid, small pupil, absence of sweating on that side of the face). I can’t specifically remember where the middle and inner ear get their sympathetic innervation from but I would have thought that is was via cervical ganglia and not cranial nerves.

          • JM-K wrote “I have certainly seen Horner’s syndrome following neck surgery…”

            Horner Syndrome after chiropractic spinal manipulation:
            https://edzardernst.com/2015/06/horner-syndrome-after-chiropractic-spinal-manipulation/

          • Julian, a fascinating ganglion.

            https://www.semanticscholar.org/paper/The-sympathetic-superior-cervical-ganglia-as-Cardinali-Vacas/5cb1e8cdf03becc46180d59177a1268dbb344557

            “ These alterations suggest that superior cervical ganglia-related feedback mechanisms play a role in SCN-periphery phase coordination and that SCGx is a valid model without brain-invasive surgery to explore how sympathetic innervation affects daily (24 h) patterns of activity, food consumption and, ultimately, its role in metabolism homeostasis.”

            https://www.frontiersin.org/articles/10.3389/fendo.2017.00370/full

            “ Cerebral sympathetic innervation originates in the superior cervical ganglion (SCG), with minor contributions from the stellate ganglia and possibly an intrinsic central adrenergic pathway (1, 11, 13). ”

            https://journals.physiology.org/doi/full/10.1152/ajpregu.00332.2007

          • ‘DC’ quoted “with minor contributions from the stellate ganglia”

            That was from a study of rodents. Up to 80% of the human population have one stellate ganglion; in the remainder it is absent.

          • Somebody: That was from a study of rodents.

            In a earlier comment I mentioned comparative neuroanatomy studies have limitations. I didn’t think I needed to share that again.

            Somebody: Up to 80% of the human population have one stellate ganglion; in the remainder it is absent.

            Some studies found up to 85% have the stellate ganglion. But I fail to see how his/her comment applies to the conversation.

          • ‘DC’ wrote “In a earlier comment I mentioned comparative neuroanatomy studies have limitations.”

            This fact has been mentioned many times over the years on this blog. I’m pointing out that the study was of rodents because you failed to do so. Reference 1 and 13 in your quote were both to studies of rodents.

            Only someone incredibly stupid would class this lack of stellate ganglia as a comparative neuroanatomy study limitation. LOL!

          • “ I’m pointing out that the study was of rodents because you failed to do so. ”

            Ok.

      • “It may be helpful to state that there is no such thing as a chiropractic adjustment. Instead, it is an adjustment by a chiropractor”

        Thanks for that. Likewise:

        It may be helpful to state that there is no such thing as chiropractic quackery. Instead, it is quackery by a chiropractor.

  • Dear Julian, In this case, I will strongly suggest that this case report DOES reflect what an RCT would concur, considering a previous pilot RCT concluded a superior outcome in headache relief by the improvement to suffering patients presenting with a cervical hypolordosis(chiropractic subluxation). I now present my evidence. https://pubmed.ncbi.nlm.nih.gov/33786392/

    • Mr Epstein,

      I will strongly suggest that this case report DOES reflect what an RCT would concur, considering a previous pilot RCT concluded a superior outcome…

      The purpose of a pilot study is to assess the feasibility of a proper trial and to identify any problems in the design at an early stage. It is not to test the intervention itself.

      The authors of the paper that you quote have this to say in the Discussion section:

      While this pilot study was inadequately powered, which might question the generalizability of the present findings to general population.

      This is lifted straight out of the paper, and wasn’t a proper sentence in the original, either.

      a previous pilot RCT concluded a superior outcome in headache relief by the improvement to suffering patients presenting with a cervical hypolordosis(chiropractic subluxation)

      The Conclusions section of the paper made no mention of headache. Have you actually read it yourself?

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