Newborn chiropractic care: Where is the evidence?
To first-time parents, handling their newborn child is like holding a tiny creature made of the most delicate porcelain — but is also as floppy as a water balloon, and utterly helpless.
It is a slightly terrifying experience, until you get the hang of it.
So what then are we to make of the chiropractic treatment of newborns, which involves cracking their spine the way you might crack your knuckles?
Spinal realignment in young children is touted as a treatment for infantile conditions such as poor breastfeeding, colic and sleeping troubles.
An online video of such a treatment being applied to a four-day-old baby by Melbourne chiropractor Ian Rossborough (which has since been made private) drew a strong response in Australia and internationally earlier this year. It makes for uncomfortable viewing: there is a loud crack, as the chiropractor pushes his two fingers into the baby’s back.
The treatment was intended to resolve the baby’s persistent crying and colic, and in later statements the chiropractor said the treatment was successful.
Dr Rossborough has since had restrictions placed on his practice.
But is there any truth to claims the process of vaginal birth mean newborns commonly have problems with spinal symmetry that require treatment?
Paediatrician Dr Jacqueline Small said no.
“There’s no evidence that there’s misalignment of the spine in the way that the chiropractors claim there is,” Dr Small said.
A baby sustaining physical trauma during childbirth would not only be highly unusual and rare, but it would also call for management by an appropriate medical specialist, she said.
Dr Small, who is chair of the Royal Australian College of Physicians’ (RACP) Paediatric Policy and Advocacy Committee and a member of the college’s Paediatrics and Child Health Division Council, said in the vast majority of otherwise healthy babies, there was no evidence of misalignment of the spinal cord.
“And there’s no evidence that this is related to any of the symptoms they might experience,” she said.
Addressing ‘imbalances in spinal symmetry’
Manipulation of the spine is a mainstay of chiropractic therapy, according to the Chiropractors’ Association of Australia. Their website states that “the practice of chiropractic focuses on the relationship between structure (primarily the spine) and function (as coordinated by the nervous system) and how this relationship affects the preservation and restoration of health”.
Chiropractors Association of Australia (CAA) spokesperson Dr Anthony Coxon said spinal realignment looked to address imbalances in spinal symmetry.
“These can cause changes in muscle tone that may over time have neurological effect, they may distort the posture, they may create muscle strains, and there is some suggestion that they may contribute to colic,” he said.
The CAA website cites a range of studies supporting the practice, but very few of these meet the so-called gold standard for clinical studies — the randomised controlled trial.
Such a trial design requires that participants are randomly allocated to a particular treatment or to a control treatment — usually either a placebo or an existing established treatment. Ideally, the participants themselves (or in this case their parents) are “blinded” to the treatment form used, so they do not know whether they have received the study treatment or the control treatment. This lessens the chance that any difference between the two treatments will be influenced by people’s expectations.
Review finds trials of insufficient quality
One 2012 study of chiropractic intervention in infants did take this approach. In it, 104 infants aged under eight weeks with unexplained persistent crying were randomised to one of three groups: manual therapy with a chiropractor in which the parents were aware of the treatment given; manual therapy in which the parents were not told of the treatment; and no therapy where the parents were also not told of the treatment given.
In all three groups, the parents completed a crying diary for the infant over the following ten days.
The study did report significant improvements in the treated infants compared to the untreated ones, regardless of whether the parents knew the treatment that was given.
Dr Coxon said of the four randomised controlled trials of chiropractic treatment for colic, three showed a benefit of treatment. So does this prove the case?
Not according to the Cochrane Collaboration, which publishes analyses that look at the sum total of studies in a particular situation and judges the overall state of play.
Its 2012 review of manipulative therapies for infantile colic, which included six randomised trials involving 325 infants, concluded that the studies were too small and of “insufficient quality” to draw confident conclusions.
Dr Coxon acknowledged there were gaps in the research when it came to chiropractic care of children, although he argued there were equally gaps in the research for mainstream medical interventions.
The other issue with treating something like colic was that it was a pretty non-specific, poorly understood condition, said Dr Small, pointing out that most colic goes away by itself over time.
“There might be any number of causes for a young baby crying, and for the vast majority, there’s no specific pathology and it will get better in time,” she said.
And the big risk with taking a colicky baby to a chiropractor was that a more serious, underlying problem could be missed, she said.
But Dr Coxon stressed that, just as a GP would refer a patient to a specialist if they felt they needed specialist treatment, so too would a chiropractor send a patient to a mainstream clinician if they felt it was warranted.
Controversy across all age groups
Spinal manipulation is controversial across all ages, because of the potential for harm. In adults, there is a risk of stroke and tearing in the inner lining of an artery in the neck and in children, there have been reports of bleeding in the brain and paraplegia.
Dr Small said there may be a risk that the spinal growth plates in newborns — the bits in between the vertebrae — might be damaged by spinal manipulation.
“Again, we don’t know how much evidence there is but it’s a theoretical possibility because there’s much more cartilage and quite delicate growth plates. So it is possible that [there] might be long term damage,” she said.
Recognising the more fragile nature of the newborn spine, Dr Coxon said the techniques applied to newborns, infants and children were very different to those used for adults.
“Best practice dictates that these techniques should be low velocity and low speed only when applied to very young children,” he said.
Ultimately, there is limited and generally poor quality evidence of the benefits of spinal manipulation on newborns — and clear evidence of the albeit small potential for major harm.
With this in mind, Dr Small said parents should ask about the risks of chiropractic treatments that are being suggested for their children.
“Even if they’re uncommon risks, if they’re severe risks where the child is otherwise healthy, then those serious risks take on a much greater significance,” she said.