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

children

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I have previously reported that a Canadian naturopath, Jason Klop,  is under investigation for selling fecal Microbiota transplants to treat autistic children. Now, there is a new twist in this story.

On Twitter, J.N. Stea summarized it nicely:

This naturopath is fighting a judge so that he can charge parents about $15,000 to give his nephew’s poop to children as a treatment for autism. His lawyer argues that he should be allowed to since naturopathy isn’t scientific anyway.

Klop’s lawyer defends the naturopath against an investigation into his business of selling fecal microbiota transplants to families of autistic children. The College of Naturopathic Physicians (CoN) had banned Klop for selling, advertising, and manufacturing pills made from human feces claiming that Klop has been engaging in conduct not acceptable for a naturopathic physician. Klop’s lawyer, Jason Gratl, argued this was difficult to prove in a field that has a few restrictions and some ambiguous boundaries.

“What does it take to be a naturopath and do something that is not appropriate in a field so wide-ranging and open to interpretation?” the lawyer, Gratl, asked the court suggesting that the lack of scientific evidence supporting the use of fecal Microbiota Transplants (FMT) to treat autism is not necessarily relevant in this instance.

“Naturopaths can rely on science in certain aspects, but they are not bound to science,” Gratl said. He explained that naturopathic practices could be based on anecdotes and historical knowledge. Later, he pointed out that the field also includes homeopathy, which, some believe, involves magical thinking. It is definitely not scientific in its core.” After describing the case as a “tragedy”, Gratl called the allegations against his client “entirely unverfounded and scurrilous.”

I suspect it is nothing new to most readers, yet I find it gratifying to hear from a lawyer that naturopathy

  • is not science,
  • relies on anecdote instead of evidence,
  • and involves magical thinking.

I do think, however, that despite all this, naturopaths should not be allowed to do any odd nonsense that comes to their minds and fills their bank accounts quickly.

The Anglo-European College of Chiropractic (AECC) has been promoting pediatric chiropractic for some time, and I have posted about the subject before  (see, for instance, here). Now the AECC has gone one decisive step further. On the website, the AECC announced an MSc ‘Musculoskeletal Paediatric Health‘:

The MSc Musculoskeletal Paediatric Health degree is designed to develop your knowledge and skills in the safe and competent care of children of all ages. Our part-time, distance-based course blends live online classes with ready to use resources through our virtual learning environment. In addition, you will have the opportunity to observe in the AECC University College clinical services at our Bournemouth campus. The course covers topics in paediatric musculoskeletal practice with specific units on paediatric development, paediatric musculoskeletal examination, paediatric musculoskeletal interventions, and paediatric musculoskeletal management. You will address issues such as risk factors and public health, including breastfeeding, supine sleep in infancy, physical activity in children and conditions affecting the musculoskeletal health of children from birth. The paediatric specific topics are completed by other optional units such as professional development, evidence-based practice, and leadership and inter-professional collaboration. In the dissertation unit you will conduct a study relevant to musculoskeletal paediatric health.

Your learning will happen through a mix of live and recorded lectures, access to online reading materials, and access to the literature through our learning services. You will also engage with the contents taught through guided activities with your peers and staff. Clinical paediatric experience is recommended to fully engage with the course. For students with limited access to a suitable clinical environment to support their studies, or for student who wants to add to their clinical experience, we are able to offer a limited number of opportunities to observe and work alongside our clinical educators within the AECC University College clinical services. Assessments are tailor made to each unit and may include a variety of methods such as critical reviews, reflective accounts, portfolios and in the last year a research dissertation.

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The AECC emphasizes its commitment to being a leading higher education institution in healthcare disciplines, nationally and internationally recognised for quality and excellence. Therefore, it seems only fair to have another look at the science behind pediatric chiropractic. Specifically, is there any good science to show that would justify a Master of Science in ‘Musculoskeletal Paediatric Health’?

So, let’s have a look and see whether there are any good review articles supporting such a degree. Here is what I found with several Medline searches (date of the review on chiropractic for any pediatric conditions, followed by its conclusion + link [so that the reader can look up the evidence]):

2008

I am unable to find convincing evidence for any of the above-named conditions. 

2009

Previous research has shown that professional chiropractic organisations ‘make claims for the clinical art of chiropractic that are not currently available scientific evidence…’. The claim to effectively treat otitis seems to
be one of them. It is time now, I think, that chiropractors either produce the evidence or abandon the claim.

2009

The … evidence is neither complete nor, in my view, “substantial.”

2010

Although the major reason for pediatric patients to attend a chiropractor is spinal pain, no adequate studies have been performed in this area. It is time for the chiropractic profession to take responsibility and systematically investigate the efficiency of joint manipulation of problems relating to the developing musculoskeletal system.

2018

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.

What seems to emerge is rather disappointing:

  1. There are no really new reviews.
  2. Most of the existing reviews are not on musculoskeletal conditions.
  3. All of the reviews cast considerable doubt on the notion that chiropractors should go anywhere near children.

But perhaps I was too ambitious. Perhaps there are some new rigorous clinical trials of chiropractic for musculoskeletal conditions. A few further searches found this (again year and conclusion):

2019

We found that children with long duration of spinal pain or co-occurring musculoskeletal pain prior to inclusion as well as low quality of life at baseline tended to benefit from manipulative therapy over non-manipulative therapy, whereas the opposite was seen for children reporting high intensity of pain. However, most results were statistically insignificant.

2018

Adding manipulative therapy to other conservative care in school children with spinal pain did not result in fewer recurrent episodes. The choice of treatment-if any-for spinal pain in children therefore relies on personal preferences, and could include conservative care with and without manipulative therapy. Participants in this trial may differ from a normal care-seeking population.

I might have missed one or two trials because I only conducted rather ‘rough and ready’ searches, but even if I did: would this amount to convincing evidence? Would it be good science?

No! and No!

So, why does the AECC offer a Master of Science in ‘Musculoskeletal Paediatric Health’?

Search me!

It wouldn’t have something to do with the notion that it is good for business?

Or perhaps they just want to give science a bad name?

On this blog, I have been regularly discussing the risks of so-called alternative medicine (SCAM). In particular, I have often been writing about the risks of chiropractic spinal manipulations.

Why?

Some claim because I have an ax to grind – and, in a way, they are correct: I do feel strongly that consumers should be warned about the risks of all types of SCAM, and when it comes to direct risks, chiropractic happens to feature prominently.

But it’s all based on case reports which are never conclusive and usually not even well done.

This often-voiced chiropractic defense is, of course, is only partly true. But even if it were entirely correct, it would beg the question: WHY?

Why do we have to refer to case reports when discussing the risks of chiropractic? The answer is simple: Because there is no proper system of monitoring its risks.

And why not?

Chiropractors claim it is because the risks are non-existent or very rare or only minor or negligible compared to the risks of other therapies. This, I fear, is false. But how can I substantiate my fear? Perhaps by listing a few posts I have previously published on the direct risks of chiropractic spinal manipulation. Here is a list (probably not entirely complete):

  1. Chiropractic manipulations are a risk factor for vertebral artery dissections
  2. Vertebral artery dissection after chiropractic manipulation: yet another case
  3. The risks of (chiropractic) spinal manipulative therapy in children under 10 years
  4. A risk-benefit assessment of (chiropractic) neck manipulation
  5. The risk of (chiropractic) spinal manipulations: a new article
  6. New data on the risk of stroke due to chiropractic spinal manipulation
  7. The risks of manual therapies like chiropractic seem to out-weigh the benefits
  8. One chiropractic treatment followed by two strokes
  9. An outstanding article on the subject of harms of chiropractic
  10. Death by chiropractic neck manipulation? More details on the Lawler case
  11. Severe adverse effects of chiropractic in children Another serious complication after chiropractic manipulation; best to avoid neck manipulations altogether, I think
  12. Ophthalmic Adverse Effects after Chiropractic Neck Manipulation
  13. Is chiropractic treatment safe?
  14. Cervical artery dissection and stroke related to chiropractic manipulation
  15. We have an ethical, legal and moral duty to discourage chiropractic neck manipulations
  16. Cerebral Haemorrhage Following Chiropractic ‘Activator’ Treatment
  17. Vertebral artery dissection after chiropractic manipulation: yet another case
  18. Horner Syndrome after chiropractic spinal manipulation
  19. Phrenic nerve injury: a rare but serious complication of chiropractic neck manipulation
  20. Chiropractic neck manipulation can cause stroke
  21. Chiropractic and other manipulative therapies can also harm children
  22. Complications after chiropractic manipulations: probably rare but certainly serious
  23. Disc herniation after chiropractic
  24. Evidence for a causal link between chiropractic treatment and adverse effects
  25. More on the risks of spinal manipulation
  26. The risk of neck manipulation
  27. “As soon as the chiropractor manipulated my neck, everything went black”
  28. Spinal epidural haematoma after neck manipulation
  29. New review confirms: neck manipulations are dangerous
  30. Top model died ‘as a result of visiting a chiropractor’
  31. Another wheelchair filled with the help of a chiropractor
  32. Spinal manipulation: a treatment to die for?

Of course, one can argue about the conclusiveness of this or that case report, but I feel that the collective evidence discussed in these posts makes my point abundantly clear:

chiropractic spinal manipulation is not safe.

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!

Osteopathic manipulative treatment (OMT) is advocated not merely for spinal or musculoskeletal problems, as many consumers seem to think, osteopaths also claim it to be effective for (almost) every condition. Some osteopaths who believe in the gospel of Andrew Still, the founder of osteopathy, recommend it even to facilitate breastfeeding.

But is it effective? 

A double-blind randomised controlled trial to answer this question was conducted between July 2013 and March 2016. Breastfed term infants were eligible if one of the following criteria was met: suboptimal breastfeeding behaviour, maternal cracked nipples or maternal pain. The infants were randomly assigned to the intervention or the control group. The intervention consisted of two sessions of early OMT, while in the control group, the manipulations were performed on a doll behind a screen. The primary outcome was the exclusive breastfeeding rate at 1 month, which was assessed in an intention-to-treat analysis. Randomisation was computer generated and only accessible to the osteopath practitioner. The parents, research assistants and paediatricians were masked to group assignment.

One hundred twenty-eight mother-infant dyads were randomised, with 64 assigned to each group. In each group, five infants were lost to follow-up. In the intervention group, 31 of 59 (53%) of infants were still exclusively breastfed at 1 month vs 39 of 59 (66%) in the control group, (OR 0.55, 95% CI 0.26 to 1.17; p=0.12). After adjustment for suboptimal breastfeeding behaviour, caesarean section, use of supplements and breast shields, the adjusted OR was 0.44 (95% CI 0.17 to 1.11; p=0.08). No adverse effects were reported in either group.

The authors concluded succinctly that OMT did not improve exclusive breastfeeding at 1 month.

Surprised?

Suppose not!

The only question that I can think of is this: why did osteopaths ever think that OMT might facilitate breastfeeding?

Aromatherapy, the use of essential oils for medicinal purposes, exists in several guises. One of them is inhalation aromatherapy which is a complementary therapy used in different clinical settings. But is there any sound evidence about its effectiveness?

The aim of this review was to assess the effectiveness of inhalational aromatherapy in the care of hospitalized pediatric patients.

A systematic review of clinical trials and quasi-experimental studies was conducted, based on PRISMA recommendations, searching Medline, Web of ScienceScopus, SciELO, LILACS, CINAHLScience Direct, EBSCO, and updated databases. The Down and Black 2020, RoB 2020 CLARITY, and ROBINS-I 2020 scales were used through the Distiller SR software to verify the studies’ internal validity and risk of bias.

From 446 articles identified, 9 fulfilled the inclusion criteria. Seven were randomized controlled trials (RCTs), one pilot RCT, and one non-randomized quasi-experimental trial.

Different outcomes were analyzed, with pain being the most frequently measured variable. None of the 6 studies that evaluated pain showed significant effects with inhalation aromatherapy. Additionally, non-significant effects were found regarding nausea, vomiting, and behavioral/emotional variables.

The authors concluded that the findings are still inconclusive, and more evidence is required from future studies with high methodological quality, blinding, and adequate sample sizes.

Inconclusive?

Really?

Call me a skeptic, but I think the findings show quite clearly that there is no sound evidence to suggest that inhalation aromatherapy might be effective for kids.

Steiner (Waldorf) schools, like anthroposophical medicine, are the inventions of Rudolf Steiner. His followers have often been associated with rampant anti-vax sentiments. Yet, officially such beliefs are usually denied.

A few days ago, I came across this tweet:

Der Dachverband der anthroposophischen Medizin begrüßt Corona-Impfungen… & distanziert sich von Querdenken und Co. Steiner war selbst gegen Pocken geimpft und ließ impfen. 

As it is in German, allow me to translate it for you:

The umbrella organization of anthroposophical medicine welcomes corona vaccinations… & distances itself from lateral thinking and co. Steiner himself was vaccinated against smallpox and had it vaccinated.

Almost simultaneously, it was reported that, after the Corona outbreak at a Freiburg Steiner school with more than 100 people infected, it is now certain: the certificates presented to the school for exemption from wearing masks were invalid.

During circus performances at the Steiner school in Freiburg, more than 100 people had become infected with the coronavirus in October: among them pupils, teachers, and contact persons. Therefore, the school inspectorate of the Freiburg Regional Council examined the certificates that freed people from the obligation to wear masks at school for health reasons. Heike Spannagel, a spokeswoman for the Freiburg Regional Council, called the results surprising. There were 55 certificates, 52 from pupils and three from teachers – and all of them were invalid. Heike Spannagel added that the school will no longer recognize any of the certificates. Those who cannot present new certificates that are more convincing will therefore have to wear the mask, Spannagel said.

It was noticeable that many certificates came from (far remote) private clinics in Bavaria or Berlin. In addition, a Freiburg doctor had exempted pupils from the obligation to wear a mask with identical justifications. According to the regional council, however, justifications must be individually tailored. In the meantime, the public prosecutor’s office in Freiburg has requested documents from the regional council in order to initiate an investigation.

So, what has been going on?

To me, it looks like the Steiner school was tolerating or even encouraging the use of dodgy certificates. This contrasts somewhat with the tweet cited above. And, in turn, this seems to indicate that proponents of anthroposophy say one thing about COVID and then do something entirely different. This suspicion was strengthened by a tweet that appeared a little while later as a response to the tweet cited above:

Alle Anhänger der Anthroposophie, die ich kenne, sind nicht geimpft. Es ist ja schön, wenn diese Verbände das öffentlich so verkünden. Die Praxis sieht leider anders aus.

Allow me to translate again:

All the followers of anthroposophy that I know are not vaccinated. It is nice when these associations proclaim this publicly. Unfortunately, the practice looks different.

Germany seems to have a significant problem with anti-vaxxers. Today, only 68% of the population has had a COVID vaccination. In the UK and France, these figures are 72% and 75% respectively.

How come?

This study investigated the willingness to vaccinate of parents of minors and people without children who are minors. The investigation was based on a random sample of Germans (telephone survey, n = 2,014, collected between 12 November and 10 December 2020). The evaluation is primarily based on the sub-sample of people with minors in the household (n = 461).

Parents of minors consistently show a lower willingness to be vaccinated with a COVID-19 vaccine than respondents without minors (54.1% vs 71.1%). Fathers show a stronger willingness to be vaccinated than mothers. Furthermore, men are more willing to get their own child vaccinated with a COVID-19 vaccine than are women.

The authors concluded that among parents and especially mothers, a considerable misrepresentation of vaccination risks and frequent beliefs in vaccination conspiracy theories can be observed. Clear and easily understandable information on the effects and side effects of vaccination with a COVID-19 vaccine by relevant institutions and physicians is recommended.

And what has this to do with so-called alternative medicine (SCAM) and homeopathy?

In the results section of the paper, the authors report interesting  additional findings (my translation):

In the total sample, a significantly higher willingness to vaccinate is associated with the rejection of “alternative healing methods”. There is also a significant correlation between the attitude towards homeopathy and one’s own willingness to vaccinate: if homeopathy is supported, the willingness to vaccinate is lower. This correlation between the attitude towards homeopathy and willingness to vaccinate is also evident in the sub-sample of parents. Among parents, it is again women who significantly more often have a positive attitude towards homeopathy than men, who more often do not think anything of it.

The authors also report that the parents were asked: “If a vaccine against the coronavirus is approved in Germany, would you get vaccinated?” CERTAINLY NOT was the answer of:

  • 41% of homeopathy fans
  • 10% of people who thought nothing at all about homeopathy
  • 15% of participants who were not fully convinced by homeopathy

Yes, Germany seems to have a problem with the anti-vaccination brigade but it seems that at the heart of it is a problem with a homeopathy cult.

 

We have covered urine therapy several times already (see for instance here, and here). Essentially it is ineffective but harmless …

except…

CTV reported that a mother in Canada has temporarily lost her right to unsupervised parenting over allegations she made her young son drink his own urine as part of a controversial so-called alternative medicine (SCAM). Specifically, she had fed the eight-year-old boy smoothies made with his own urine.

Apparently, the mother began pursuing a fringe “natural and holistic” lifestyle about three years ago. “It has created significant distrust by the (father) as to the respondent’s judgment in ensuring that the child is safe in her care, which came to a head when the allegation that she was imposing urine therapy on the child arose,” the judge wrote.

The mom’s interest in alternative medicine previously resulted in her seeking unsupported remedies such as homeopathy to treat her breast cancer – all of which failed, ultimately leaving her with no choice but to undergo surgery. Eventually, that inclination also brought her to urine therapy, described in the decision as “a centuries-old practice of drinking one’s own urine and massaging it into one’s skin.”

The mother admitted in court that she started drinking her own urine last January, and even that she appeared on an obscure podcast called “Healing Powers of Urine Therapy,” but denied forcing her son to take part in the practice. The father recounted an after-school incident in which the child approached him looking confused and guilty and said, “I have a secret, you have to promise me not to tell mom. Mom made me pee in a jar, then she put the pee into my fruit smoothie.” The boy later repeated the allegations during an appointment alone with their family doctor. The child said he “didn’t want to do it, told his mom he didn’t want to but she encouraged him to.”

There were also concerns raised about the mother’s fasting, which the father said went on for days on end and left her physically incapable of caring for their son. The judge wasn’t convinced that foregoing food left the mom unable to parent, but ultimately said she agreed with the father’s assessment that, while his former partner loves their son, her “judgment and health are questionable at this time.” The judge ruled that the mother can have parenting time from Sunday mornings to Wednesday evenings, but only with supervision from a professional or a third party agreed upon by both parents.

_________________

The case shows that, once a gullible consumer falls under the influence of the SCAM cult and goes ‘off the rails’, there are no limits. This woman started by treating her cancer with homeopathy and, even though this was not successful, she continued to slide down the slippery SCAM slope until, finally, she experimented with urine therapy on her own son. This indicates to me that we might have to add another risk to the many dangers of homeopathy: it can serve as a gateway drug for all sorts of other SCAMs.

I was alerted the these Chiropractic Paediatric Courses. After studying the material, I was truly stunned. Now that I have recovered, I feel I should share it with you:

Chiropaeds Australia is an approved and accredited provider of the Diplomate of Australian College of Chiropractic Paediatrics program.

Diplomate of Australian College of Chiropractic Paediatrics Offered for the first time in 2013, the Diplomate program is a two-year chiropractic paediatric course. This course is ideal for the family chiropractor wanting to improve his or her knowledge in chiropractic paediatrics. The emphasis is on conditions and management issues which are commonly seen by the family chiropractor.

The course is structured around 20 four-week modules over two years. Each module consists of required reading, exercises and at the end of each four-week module there is a six-hour seminar. Each six-hour seminar will reinforce the reading and develop the practical and management skills needed to feel confident in providing optimal chiropractic care for children…

Registration post 31 December – $AUD 6050 (includes GST) This covers the cost of all materials and seminars but does not include any books or texts you may decide to purchase.

To provide you with an impression of the content of the modules, I have chosen three of them. Here they are:

Module 7

Neurological assessment of the infant
1. Neurological examination of the infant (Infanib)
2. Motor issues: diagnosis and chiropractic management
a. Gross motor developmental delay
b. Hyper/ hypotonia
c. Cerebral palsy
It is only by knowing how to assess the infant’s neurological system that you can start to fully appreciate and understand the immense impact of the subluxation. The information covered in this module allows you to demonstrate to your parents the impact the subluxation has on their infant’s nervous system. As a result your subluxation diagnosis, treatment and management with infants will be enhanced. We look at muscle function issues which occur in this age group with particular emphasis on gross motor developmental delay and hyper/hypotonia.

Module 8
Neurological assessment of the pre-schooler and the school aged child
1. Gross motor function
2. Fine motor function
3. Cerebellar function
4. Assessment of higher cognitive functions
5. Visual processing
6. Auditory processing
7. Language development
Syndrome management
1. Auditory processing syndromes
2. Visual processing syndromes
Chiropractic has a major role to play in treating and managing children with learning difficulties. Crucial to optimal outcomes is an ability to fully assess and determine the particular issues and neurological problems your patient experiences. This module is very practical: you will learn how to accurately test cortical and cerebellar function in preschool and school aged children to a very advanced level. Being able to perform extensive testing of learning ability in children will assist you to accurately find and monitor their learning difficulties. The interplay of higher cortical function, cerebellar function and the subluxation is explored and the impact of your consultation assessment routine on the subluxation is addressed. Management of learning difficulties is emphasised.

Module 11
The child’s ear, nose and throat
1. Acute otitis media
2. Chronic otitis media
3. Serous otitis media
4. Nose and throat issues with children
5. Tonsillitis, epiglottitis, coup and neck abscesses
Chiropractors have a key role to play in the treatment and management of otitis media along with other conditions associated with recurrent viral infection as well as decreased or imbalanced immune system function. We cover the diagnosis of each condition along with chiropractic treatment and management, including the interaction of the subluxation and the immune system. Nutritional management is also covered. Key management issues are explored and literature based knowledge is provided to allow you to educate you patient’s parents. This fosters improved compliance with your care and permits you to expand the boundaries of your chiropractic care of children.

____________________________________

I wonder whether some chiropractor feels like defending this outright charlatanry.

I know of no evidence to assume that chiropractors can provide effective care for children. I see, however, many reasons to fear that they may cause considerable harm. I also see no reason to take a profession seriously that tolerates or even supports such extreme quackery.

I have expressed these concerns often enough, e.g.:

In my view, it is high time to stop this dangerous nonsense.

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