Hewitt Handouts 2009 April 6 Per

1
Pediatrics for the Chiropractor: Spinal

Adjusting and Treatment Protocols for
Common Pediatric Conditions
Presented by:
Elise G. Hewitt, DC, CST, DICCP, FICC
Portland Chiropractic Group
2031 E. Burnside Street
Portland, Oregon 97214
503.224.2100
www.DrEliseHewitt.com
drelise@portlandchiropracticgroup.com
Tools of the Chiropractic Trade
! Depending on state, scope of practice includes:
! Manual therapies (manipulation, massage, CST, etc.)
! Physiotherapies
! Exercise and postural advice
! Herbal and nutritional supplements
! Lifestyle and dietary advice
all to enhance health of child
! Chiropractors are much more than just spinal
adjusters
! Chiropractors are doctors
Clinical Rationale for Manual
Therapy Aspects of Chiropractic
Care
! Chiropractors seek to restore normal biomechanics
to the articulations of the body with the aim of
normalizing neurological and physiological
function to local and systemic structures related to
the affected joints.
SUBLUXATION
KINESIOPATHOPHYSIOLOGY NEUROPATHOPHYSIOLOGY
HISTOPATHOPHYSIOLOGY
ANGIOPATHOPHYSIOLOGY
MYOPATHOPHYSIOLOGY
Local Effects of a Subluxation
INFLAMMATION
IMPAIRED NUTRIENT DELIVERY
& WASTE REMOVAL
MUSCLE SPASM
NERVE FACILITATION
OR INHIBITION
RESTRICTED JOINT MOTION
PAIN
Systemic Effects of a Subluxation
! Body has inherent self-regulatory mechanisms
Homeostasis = balance
! Subluxation can interfere with these mechanisms by
altering function in neurological and vascular systems,
creating dis-ease
Dis-ease = imbalance = asymptomatic malfunction
! Long-term consequence of dis-ease is disease
Disease = symptomatic malfunction
! Aim of chiropractic is to strengthen host and restore
normal regulatory mechanisms by removing cause of
pathophysiology (subluxation)
Preferably before dis-ease progresses into disease
Systemic Effects of a Subluxation -
Research
! Leboeuf-Yde, Pedersen et al performed a survey of 5,600 chiropractic
patients in 7 countries to determine the nature and frequency of non-
musculoskeletal health benefits associated with their chiropractic
treatment.
! 25% of all patients reported at least one positive non-
musculoskeletal response (non-MSR).
! Most common improvements were for complaints related to the
respiratory, digestive and circulatory systems.
Leboeuf-Yde C, Pedersen EV, Bryner P et al. Self-reported nonmusculoskeletal responses to
chiropractic intervention: a multination survey. J Manipulative Physiol Ther 2005;28:294-302.
! Rosner in a 2003 analysis of the state of pediatric chiropractic
research found compelling outcomes for otitis media, colic and
asthma. More recent studies include promising results for nursing
dysfunction, constipation, headaches, neurological disorders (incl.
autism, ADD/ADHD)
Rosner A. Infant and child chiropractic care: an assessment of the research. Foundation for
Chiropractic Education and Research. Norwalk, IA. 2003.
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Research
! Klougart in cohort study of 316 infants with colic treated in 50 different
chiropractic clinics found significantly reduced symptoms in 92%
following three treatments over a 2-week period.
Klougart N, Nillson N, Jacobsen J. Infantile colic treated by chiropractors: a prospective study of 316 cases.
J Manipulative Physiol Ther 1989;12(4):281-88.
! Mills et al in RCT involving 57 children with recurrent otitis media (OM)
found those receiving manipulative therapy (OMT), as compared to those
receiving routine pediatric care, had fewer episodes of OM, fewer surgical
procedures and higher rates of normal tympanograms.
Mills MV, Henley CE, Barnes LLB et al. The use of osteopathic manipulative therapy as adjuvant therapy
in children with recurrent acute otitis media. Arch Ped Adolesc Med 2003;157(9):861-66.
Research
! Bakris et al Journal of Human Hypertension 2007: found that
chiropractic adjustments to the cervical spine created marked and
sustained reductions in blood pressure equivalent to the use of a
two-drug combination therapy.
Bakris G, Dickholtz M, et al. Atlas vertebra realignment and the achievement of arterial pressure
goal in hypertensive patients: a pilot study. Journal of Human Hypertension 2007;21:347-352.
! Haavik-Taylor and Murphy in Clinical Neurophysiology 2006:
measured changes in somato-evoked potentials in frontal and
parietal lobes of brain following cervical adjustments. Found that
cervical adjustments reduced excessive afferent signals in the brain
and altered cortical somatosensory processing and sensorimotor
integration. No changes were noted in the passive range of motion
control group.
Haavik-Taylor H, Murphy B. Cervical spine manipulation alters sensorimotor integration: a
somatosensory evoked potential study. Clinical Neurophysiology 2006;118(2):391-402.
Why Children Need Chiropractic
Care
! Recent trauma for neonates (birth)
! Time of greatest spinal elongation
! Time of spinal curvature development
! Heuter-Volkmann law
! To optimize function of nervous system
! Time of proprioceptive development
! Time of greatest brain growth
Causes of Subluxation
! Trauma
! In utero constraint - including multiples
! Prolonged or precipitous birth
! Malposition, malpresentation
! Assisted delivery - forceps, vacuum extraction, Caesarean section
! Falls, car accidents, bike crashes, mishandling, etc.
! Gravitational forces and bipedal posture
! Spine designed like suspension bridge in quadrupeds
! Upright posture changes the way forces are transmitted through spine
! creates adaptive curvatures
! increases likelihood of subluxation formation
! exacerbated by prolonged poor posture; ex> screen time
Why Children Are Often Unaware of
Subluxations
! Ligament laxity
! Immaturity of joint structures
! Lack of structural/degenerative changes
! No repetitive spinal loading
! Increased whole body movement
Unique Aspects of the Pediatric Spine
! Bone
! Cartilage vs. osseous tissue
! Primary vs. Secondary ossification
! Soft Tissue
! Ligament structure
! Conclusions
! Children have the equivalent of an unstable,
hypermobile spine
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Is Chiropractic Care Safe?
! Boyle et al compared incidence rates of vertebrobasilar artery (VBA)
stroke and chiropractic utilization rates in 2 Canadian provinces from 1993-
2004. Found that VBA stroke rates increased without a corresponding
increase in chiropractic utilization. Concluded: At the ecological level,
the increase in VBA stroke does not seem to be associated with an increase
in the rate of chiropractic utilization.
Boyle E, Cote P et al. Examining vertebrobasilar artery stroke in two Canadian provinces. Spine.
2008;33(4S)Neck Pain Task Force:S170-175.
! Cassidy et al looked at incidence rates of VBA stroke following visits to a
chiropractor compared to visits to a primary care physician (PCP). Looked
at all VBA strokes from 1993-2002 (818 strokes over 100 million person-
years). Concluded: We found no evidence of excess risk of VBA stroke
associated with chiropractic care as compared to primary care. Just as
likely to suffer a stroke after visiting the PCP as after visiting a
chiropractor.
Cassidy D, Boyle E et al. Risk of vertebrobasilar stroke and chiropractic care: results of a population-based
case-control and case-crossover study. Spine. 2008;33(4S)Neck Pain Task Force:S176-183.
! Herzog et al 2002 studied actual forces within vertebral artery (VA) during:
1) normal range of motion, 2) diagnostic testing and 3) cervical
manipulation. Found that maximum forces on VA from manipulation are
less than the strain during normal daily neck movements and that
manipulation is very unlikely to mechanically disrupt the VA.
Symons B, Leonard T, Herzog W. Internal forces sustained by the vertebral artery during spinal
manipulation. J Manipulative Physiol Ther 2002;25(8):504-10.
! Thiel et al evaluated incidence of adverse events (AE) following spinal
manipulation in 19,722 patients (50,276 cervical manipulations) in U.K.
Found no serious AE. Concluded: the risk of serious adverse events,
immediately or up to 7 days after treatment, was low to very low.
Thiel HW, Bolton JE et al. Safety of chiropractic manipulation of the cervical spine: a prospective national
study. Spine 2007;32(21):2375-2378.
! Vohra et al performed a systematic review of the incidence of adverse
events (AE) following spinal manipulation in children. Review covered all
literature for past 110 years. Found 9 cases of serious AE, with estimated
30 million annual pediatric visits to the chiropractor.
Vohra S, Johnston BC, Cramer K, Humphreys K. Adverse events associated with pediatric spinal
manipulation: a systematic review. Pediatrics. 2007;119:275-283.
! Miller et al examined 781 pediatric patients under 3 years of age (73.5% of
whom were under 13 weeks) who received a total of 5242 chiropractic
treatments at a chiropractic teaching clinic in England from 2002-2004.
85% of parents reported improvement; 7 reported a minor adverse effects;
there were no serious adverse effects (reaction lasting >24 hours or needing
hospital care).
Miller JE, Benfield K. Adverse effects of spinal manipulation therapy in children younger than 3 years: a
retrospective study in a chiropractic teaching clinic. Jour Manip Physiol Ther 2008;31(6):419-422.
! Modifications are made in adjustive procedure to
adapt to the pediatric spine:
! Modified contact
! Modified patient positioning
! Decreased force
! Decreased amplitude of thrust
Adjusting Technique Modifications
for the Pediatric Spine
! Speed of thrust
! Increase compared to adult patient
! Why? - increased flexibility of tissues
! Force of thrust
! Decrease compared to adult patient
! Why? - smaller point of contact
! Contact Points
! Audible release
! Be flexible and make it fun!
Pediatric Adjusting Techniques by
Region
! Age ranges: newborn/infant, toddler/pre-
schooler and school age
! Regions: sacroiliac, lumbar, thoracic and
cervical
! Pediatric adjusting: spinal examination and
adjustive techniques
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Region - Sacroiliac Joints
! NEWBORN-INFANT
! EVALUATION
! Observe gluteal crease
! Observe gluteal folds
! Observe thigh folds
! Motion palpate SI joints and sacral segments
! ADJUSTMENT
! Leg as lever
! Prone assisted
! Prone drop
! TODDLER-PRESCHOOLER
! EVALUATION
! Evaluate leg length (at extension, 90 flexion)
! Evaluate maximal knee flexion
! Observe buttock height (pockets and pants seam)
! Motion or prone palpation of SI joints and sacral
segments
! ADJUSTMENT
! Leg as lever
! Prone assisted or drop
! Side posture, when big enough
! SCHOOL AGE
! EVALUATION (same as toddler)
! Evaluate leg length (at extension, 90 flexion)
! Evaluate maximal knee flexion
! Observe buttock height (pockets and pants seam)
! Motion or prone palpation of SI joints and sacral
segments
! ADJUSTMENT
! Side posture
! Prone drop
Region - Lumbars
! NEWBORN-INFANT
! EVALUATION
! Palpate P -> A translation prone across lap
! Non-palpating hand supporting chest and distal shoulder
! ADJUSTMENT
! Prone thumb-index finger with child in same position
! 3 parts: impulse with palpating hand, slight spread of
legs, slight lift with non-palpating hand
Region - Lumbars
! EVALUATION
! Palpate lumbar spine while sitting on parents lap or
while prone (on parents lap, on doctors lap, on table)
! ADJUSTMENT (same as SI region)
! Leg as lever
! Prone drop
! Side posture, when big enough
Region - Lumbars
! SCHOOL AGE
! EVALUATION
! Motion or prone palpation of lumbar spine
! Watch for dip at L4-L5-S1 sps - possible
spondylolisthesis; x-ray to confirm
! ADJUSTMENT (same as SI region)
! Side posture
! Prone drop
! If find spondy, adjust segment above and have child do
pelvic tilt exercises for life
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Region - Thoracics
! NEWBORN-INFANT
! EVALUATION
! Evaluate P->A translation with baby prone, over edge of
table on doctors lap, against doctors chest, or against
parents chest
! Older infant can also sit on doctors or parents lap
! As baby gets older, also evaluate rotation and lateral flexion
! ADJUSTMENT
! P->A translatory adjustment accomplished in several
ways: hanging distraction, against doctors chest, parents
chest or on table.
! Double thumb, single thumb, covered thumb or fingertip
Region - Thoracics
! EVALUATION
! Prone on table (preferred) or parent, or sitting on
parents or doctors lap
! ADJUSTMENT
! Prone:
! Bilateral or unilateral pisiform/knife-edge
! Upper thoracics: covered thumb, combo adjustment
! Lower thoracics: often easier side posture due to
extreme flexibility
! Supine: give stuffed animal to hug
Region - Thoracics
! SCHOOL AGE
! EVALUATION
! Prone on table
! ADJUSTMENT (same as toddler)
! Prone:
! Bilateral or unilateral pisiform/knife-edge
! Upper thoracics: covered thumb, combo adjustment
! Lower thoracics: often easier side posture due to
extreme flexibility
! Supine: give stuffed animal to hug
Region - Cervicals
! NEWBORN-INFANT
! EVALUATION
! Palpate suboccipital region for spasm, heat, etc.
! Palpate atlas tp (located directly inferior to mastoid)
! Motion palpate occiput and remainder of C spine (if can
find it)
! ADJUSTMENT
! Lower Cervicals: supine rotation or lateral flexion correction
! Atlas: correct laterality with fingertip contact
! Occiput: unilateral or bilateral (see next slide)
Region - Occiput Adjustment
! NEWBORN-INFANT
! Unilateral
! Patient Supine
! Rotate head 90 away from affected side
! I -> S tissue pull onto mastoid process
! Contact mastoid with 2nd mp joint
! Rotate head back to 45 away from affected side
! Line of drive toward opposite axilla
! Bilateral
! Patient supine, roll under neck
! Contact forehead with thenars or knife-edge
! Line of drive S->I and A->P
! Can use toggle drop piece
Region - Cervicals
! EVALUATION
! Supine on table, supine across parents lap, or supine on supine
parent, or sitting on parents lap
! ADJUSTMENT
! Contact using thumb, or PIP or DIP of index nger
! Supine: rotation or lateral exion correction
! Sitting: rotation or lateral exion correction
! Trick: Demo movement before actually do adjustment
! Trick: Distract patient (heels together, wiggle toes, hands on belly
button, etc.) - dont wait for them to do the move, adjust as soon as
they think about doing the move.
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Region - Cervicals
! SCHOOL AGE
! EVALUATION
! ADJUSTMENT
Both are the same as with an adult, only adjustment
involves increased velocity, decreased force and
much more fun!
About ACA Pediatrics Council
! www.acapedscouncil.org
! Membership is $85/year
! Includes quarterly newsletter, discount on Annual
Symposium registration fees, listing in locator
directory, access to list serve
! This years Pediatrics Symposium:
! October 30- 31, 2009 in St. Louis
! Part of ACA Super Conference with several other councils
! Sessions on pediatric adjusting, nutrition, and more
Conditions that Respond Well to
Chiropractic Care
! Colic/irritability
! Plagiocephaly
! Sutural ridging
! Torticollis/Head tilt
! Brachioplexis irritation
! Poor sleep
! Nursing dysfunction
! Gastroesophageal reflux
disease (GERD)
! Chronic constipation
! Sleep apnea or snoring
! Asymmetrical crawl or
gait
Neonate-Infant
Chiropractic Care
! Toddler and Pre-School Age Child
! Chronic ear infections
! Chronic upper respiratory infections
! Asthma
! Growing pains/foot or leg cramping
! Primary or secondary diurnal or nocturnal enuresis
! Incontinence (bowel or bladder)
! Pervasive developmental disorder*
*including autism, sensory integration disorder, ADD,
ADHD, learning disabilities
Chiropractic Care
! School-Age Child & Adolescent
! Back pain
! Neck pain
! Headaches
! Scoliosis
! Gait Abnormalities
! Extremity injuries (chronic ankle sprains, knee pain, shoulder
pain, etc.)
! Chronic constipation
! Chronic abdominal pain
! Chronic upper respiratory illness
Frequency of Care for Infants and
Children
! Children respond much more quickly than adults, so
initial treatment plan usually relatively short
compared to adults.
! Response proportional to age and degree of trauma
! Older child or one with greater degree of trauma may
require more care
! Typical neonate with dysfunctional nursing:
! 2x/wk 1-2 weeks, 1x/wk 1-2 weeks
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Partnership with Pediatricians
! Pediatric medical care and pediatric chiropractic
care complement each other
! crisis care vs. quality of life care
! Example: child with chronic ear infections
! MD offers antibiotics if crisis (only 5% of cases)
! DC offers:
! Adjustment and craniosacral therapy
! Lymphatic drainage to promote lymph flow
! Ear drops, natural immune enhancing supplements
! Probiotics to repair gut from repeated antibiotics
! Dietary advice to aid healing, prevent recurrences
Condition-Specific Treatment Tools
and Protocols
! Otitis Media
! Asthma
! Congenital Torticollis
! Clinical Rationale
! State of Research
! Treatment Tools
! Treatment Protocols
Chronic Otitis Media
http://emedicine.medscape.com/article/803090-overview
Chronic Otitis Media -
Clinical Rationale
! Fluid in the middle ear cavity drains through the
Eustachian tube (ET)
! Constriction of the ET may lead to OM
! ET diameter is controlled by the surrounding tensor veli
palatini muscle (TVP)
! innervated by the trigeminal nerve (CN V)
! Secondary regulation by the levator veli palatini muscle
(LVP) and the salpingopharyngeus muscle (SP)
! both innervated by the vagus nerve (CN X)
! Superior cervical sympathetic ganglion has communicating fibers
with the vagus nerve
Clinical Rationale
! Irritation of CN V or CN X can lead to increased tone in TVP,
LVP, SP muscles
! Irritation of the superior cervical sympathetic ganglion secondary to a
cervical subluxation can affect CN X
! Cranial subluxations can create irritation of CN V
! Increased tone of these muscles can result in constriction or
closure of the ET
! Closure of the ET creates pressure changes and fluid buildup in
the middle ear = otitis media w/effusion (OME)
! Both pressure & effusion can be painful, despite lack of infection
! Eventually, fluid may become infected with pathogen (viral or
bacterial) = acute otitis media (AOM)
Clinical Rationale
! Antibiotics often used at this point, but since the underlying
cause of effusion has not been addressed, fluid often remains
and recurrent infections occur.
! This typically leads to repeated courses of antibiotics
! Spinal and cranial adjustments remove the subluxation, which
relieves the neurological irritation (of the trigeminal, vagus
nerves and/or superior cervical sympathetic ganglion), which
releases the TVP/SP/LVP spasm, which allows fluid to once
again drain through the ET, relieving the root cause of the
OM.
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SUBLUXATION
MYOSPASM IN TENSOR VELI PALATINI MUSCLE
OCCLUSION OF EUSTACHIAN TUBE
POOLING OF FLUID IN MIDDLE EAR
BACTERIAL/VIRAL GROWTH AND INFECTION
ANTIBIOTICS TO KILL
BACTERIA
PATHOGEN
REGROWTH
REPEATED USE
OF ANTIBIOTICS
How a Subluxation Can Lead to Otitis Media
Otitis Media -
State of Research
! RCT, case series and case studies for over 450 patients
support theory that manual care can help children with OM
! Most cases resolve within 10 days, fewer than 5
adjustments
! Many require only 1-2 treatments
Remember, Sackett said The practice of evidence based
medicine means integrating individual clinical expertise with

the best
available external clinical evidence from systematic research.
Sackett DL, Rosenberg WMC, Gray JAM, Haynes RB, Richardson WS. Evidence based medicine:
what it is and what it isn't. BMJ 1996;312:71-72 (13 January).
Otitis Media -
State of Research
! Mills MV, Henley CE, Barnes LLB, Carreiro JE, Degenhardt BF. The
use of osteopathic manipulative treatment as adjuvant therapy in
children with recurrent acute otitis media. Archives of Pediatrics and
Adolescent Medicine 2003; 157(9): 861-866.
! RCT of 57 patients (25 in intervention group, 32 in control) with hx of
chronic OM; intervention group received OMT with routine pediatric care,
control group routine pediatric care only.
! Intervention

patients had fewer episodes of AOM (mean group difference
per month, -0.14 [95% confidence interval, -0.27 to 0.00]; P = .04), fewer
surgical procedures (intervention patients, 1; control patients, 8; P = .03),
and more mean surgery-free months (intervention

patients, 6.00; control
patients, 5.25; P = .01). Baseline and final tympanograms obtained by the
audiologist showed an increased frequency of more normal
tympanogram types in the intervention group, with an adjusted mean
group difference of 0.55 (95% confidence

interval, 0.08 to 1.02; P = .02).
No adverse reactions were

reported.
Otitis Media -
State of Research
! Degenhardt BF, Kuchera ML. Osteopathic evaluation and
manipulative treatment in reducing the morbidity of otitis media: a
pilot study. Journal American Osteopathic Assn 2006;106(6):327-
334.
! Small sample, showed OMT may be effective for chronic OM
! Fallon JM. The role of the chiropractic adjustment in the care and
treatment of 332 children with otitis media. Journal of Clinical
Chiropractic Pediatrics 1997; 2(2): 167-183.
! 332 consecutive pnts with OM; found strong correlation between
CMT and resolution of OM
! Froehle RM. Ear infection: A retrospective study examining
improvement from chiropractic care and analyzing for influencing
factors. Journal of Manipulative and Physiological Therapeutics
1996; 19(3): 169-177.
! 45 children with OM; 93% improved; 43% with 1-2 txs
Otitis Media -
State of Research
! Fysh PN. Chronic recurrent otitis media: Case series of five
patients with recommendations for case management. Journal of
Clinical Chiropractic Pediatrics 1996; 1: 66-78.
! All cases resolved following course of CMT; no complications, no
tympanostomy tubes needed
! Sawyer CE, Evans RL, Boline PD, Branson R, Spicer A. A
feasibility study of chiropractic spinal manipulation versus sham
spinal manipulation for chronic otitis media with effusion in
children. Journal of Manipulative and Physiological Therapeutics
1999; 22(5): 292-298.
! 22 pnts, aged 6 mo-6 yrs.; active SMT group had less parent-reorted
symptoms; no serious adverse events in either group.
Otitis Media -
Treatment Tools and Protocols
! Manual therapies
! Supplements
! Parent Education
! Addressing underlying causes
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Treatment Tools for OM:
Manual Therapies
! Spinal adjustments
! Check entire spine (Everything is connected to
everything else - Gonstead)
! Occiput often involved
! According to Fallon, alters pressure gradient in middle ear,
inhibiting drainage.
! To perform adjustment, rotate head 45 towards opposite
shoulder, contact mastoid with 2nd mp jt, superior tissue pull,
line of drive towards opposite axilla.
! Craniosacral therapy (or other form of cranial work)
! Again, check entire craniosacral system
! Temporal bones often involved
Manual Therapies
! Soft tissue modalities
! Lymphatic drainage
! Helps lymph flow through system; flow often inhibited due to
muscle spasm 2 to subluxations; spasm often resolves
following adjustments, allowing lymph to flow.
! If significant lymphatic congestion remains, gently massage
along lymphatic channels in direction of heart.
! Endonasal procedure
! Os located near nasopharynx and adenoids
! Post-nasal drainage can create mucus plug at os
! Endonasal is technique to remove mucus plug
! For a description of this procedure, see
http://www.healing.org/only-6.html
Supplements
! Herbal ear drops
! to treat acute infections
! Immune Support:
! Echinacea for bacterial infections
! Sambucus (elderberry) for viral infections
! Homeopathic immune tincture for babies
! GI Support: probiotics and prebiotics
! Critical for children who have been on antibiotics
! Mucus drainage: N-Acetyl Cysteine
! Foundational Nutrition
! Multivitamin, vitamin C, essential fatty acids daily
Supplements
! Herbal ear drops
! Purpose: mild analgesic, mild antibiotic
! Source: Kids Ear Drops by Eclectic Institute
! www.eclecticherb.com, 503-668-4120
! Dosage: 2-4 drops tid
! Note: drops should be warmed under tap water in dropper before
inserting into affected ear; have parent lightly traction pinna to
encourage drops to reach TM; have child remain supine for a few
minutes with head rotated toward non-affected side; some of
product will drain from ear - this is normal.
Supplements
! Immune Support:
! Echinacea for bacterial infections
! Purpose: encourages immune response to bacterial agent
! Source: Biostim Echinacea by Eclectic Institute
! Dosage: 15 drops tid, in small amount of juice
! Sambucus (elderberry) for viral infections
! Purpose: encourages immune response to viral agent
! Source: Kids Elderberry by Eclectic Institute
! Dosage: 15 drops tid for children over 1-yo
Supplements
! Immune Support:
! Homeopathic immune tincture for babies
! Purpose: encourages immune response in infants
! Source: Thymactiv by Integrative Therapeutics
! www.integrativeinc.com, 800-931-1709
! Dosage: 15 drops tid
! Note: since product is a homeopathic, it must be kept as pure as
possible; therefore, attempt to deliver dosage without child touching
dropper.
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Supplements
! Gastrointestinal Support: Probiotics
! Purpose: re-colonization and support of normal
gastrointestinal flora
! Play an important role in digestion and immune function
! Often low in children with history of antibiotic usage
! Source: Childrens Probiotic Powder by Integrative
Therapeutics
! Dosage: infant: 1/8 tsp qd-bid; older child: 1/4 tsp bid
! Use product that contains prebiotics:
! Fructooligosaccharides (inulin, etc.)
! Enhance stabilization and optimize performance of probiotics
Supplements
! Mucus Drainage
! N-Actyl L-Cysteine (NAC)
! Purpose: antioxidant; promotes mucus drainage
! Source: NAC by Integrative Therapeutics
! Dosage: 1/2 capsule bid, opened & mixed in food
Supplements
! Foundational Nutrition:
! Multivitamin
! Purpose: provides basic nutrients not found in typical diet
! Source: Liquid Multivitamin from Integrative Therapeutics,
Multigenics Chewable from Metagenics
! www.metagenics.com
! Dosage: 1-2 yo 1 tsp liquid qd; 3-4 yo 1 chewable qd; 5-10 yo
1 chewable bid; over 10-yo 2 chewables bid
! Vitamin C
! Purpose: antioxidant and immune support
! Source: Ultra-Potent C Chewable from Metagenics
! Dosage: 2-7 yo 1 qd, over 7-yo 1 bid
Supplements
! Foundational Nutrition:
! Essential Fatty Acids
! Purpose: important for nerve cell growth, skin health, and lots
more; not typically found in childs diet.
! Source: Metagenics for EPA-DHA, rest from Nordic Naturals
www.nordicnaturals.com
! Dosage: product varies by age of child
! DHA Jr (chewable): 1-3 yo 2 bid; 3-5 yo 3 bid;
! ProOmega (chewable): 5-10 yo 1 bid; over 10-yo 2 bid
! EPA-DHA Extra Strength (not chewable): over 10 yo 1 bid
! Nursing infant: have mother take Metagenics EPA-DHA 1 tid
! Non-Nursing infant: DHA Jr. Liquid: 1/4 tsp qd
Parent Education
! Reassure parents that most children with
OM will recover without antibiotics
! Spontaneous resolution rate 81%
! Therefore, less than 20% will need antibiotics
! Compare that to 93% resolution rate with antibiotics
(So antibiotics are only helping 12%!)
! Most likely, chiropractic care can significantly
increase rate of resolution without antibiotics
Parent Education
! Educate parents about role of fever in illness
! Fever is bodys way of combating pathogen - heat
denatures cell walls of pathogen
! As result, want to let fever run, if safe for child
! Use childs demeanor, rather than number on
thermometer as guide:
! if child is relatively comfortable, drinks liquids, is interested in
quiet play, let fever run its course.
! If child is lethargic, very uncomfortable, not interested in any
activities, then take measures to lower fever (cool compress,
ibuprofin, etc.)
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Parent Education
! Educate parents about ineffectiveness of
OTC cold and cough remedies for children
Parent Education
! Educate parents about ineffectiveness of OTC
cold and cough remedies for children
! FDA recommends OTC cold remedies not be use in children under
2-yo.
! FDA advisory committee voted to ban all such products for
children under 6-yo.
! There is no evidence that pediatric cold medicines provide any
relief to children suffering from colds.
! There are growing reports of deaths, convulsions, rapid heart
rates, and some loss of consciousness associated with these
medications.
! From Renewed Warning on Cold Medicines by Gardiner Harris, New York
Times, January 15, 2008, p. A15.
Parent Education
! Home Remedies
! Humidifier in childs room
! Warm compress affected over ear
! Soothes aching ear
! Dampen wash cloth with warm water
! Cover affected ear with wash cloth
! Temporarily eliminate dairy from childs diet
! Dairy contains adherens - proteins which adhere to mucus
membranes and aggravate already inflamed tissues
! Parents must be careful to avoid all foods that contain dairy
(anything that comes from a cow)
! Watch for processed foods that contain milk solids, etc.
Parent Education
! Home Remedies
! Wet sock treatment - Chinese medicine technique
! Draws heat and mucus out of head, stimulates immune system
! At bedtime, dampen pair of thin cotton socks with cold water and
put on child; ideally done after warm bath
! Cover with pair of thick socks (preferably wool or polypro.) and
have child go to sleep
! When child awakes in morning, cotton socks will be dry
! Homeopathic remedies
! Several books written for parents that allow parent to choose
remedy based upon a description of childs symptoms.
! Example: Everybodys Guide to Homeopathic Medicines by
Stephen Cummings, Dana Ullman
Otitis Media -
Treatment Protocols
! Initial Phase
! 2-3x/week for 2 weeks
! Treat with spinal adjusting, craniosacral therapy, herbal
ear drops (if acute), immune support (if acute),
foundational nutrition, parent education;
! If adequate progress, continue weekly until spinal and
cranial findings are normal, typically 2-4 weeks
depending upon degree of chronicity.
! Note: an incident of AOM may occur during this
treatment phase, but cases are usually less severe and
resolve faster than pre-treatment.
Otitis Media -
Treatment Protocols
! At end of 2nd week, if biomechanical findings improve,
but TM shows no improvement, use endonasal procedure
1x/4 days for 2-4 treatments (until os is clear).
! Rationale: likely resolution of ET constriction, but drainage
prevented by mucus plug in os.
! If continued recurrence, inflammation and/or middle ear
effusion after manual care and endonasal, then begin
searching for underlying cause(s) of chronic inflammatory
state.
! Once this is discovered and corrected, chronic inflammation and
chronic OM will disappear
12
Otitis Media -
Addressing Underlying Causes
! Gastrointestinal Dysbiosis
! Common sequela to antibiotic therapy
! Disruption of optimal growth of synergistic
microorganisms in the colon " growth of pathogenic
organisms
! Creates inflammation of gastrointestinal (GI) lining
which prevents proper nutrient absorption and interferes
with function of immune cells in GI tract.
! Common GI symptoms: constipation and/or diarrhea,
abdominal gas, bloating, and/or discomfort
! Can lead to leaky gut syndrome, food allergies, atopic
dermatitis and chronic inflammation beyond GI tract
(including soft tissues around os of Eustacian Tube).
Otitis Media -
! Diagnosis via stool testing
! Source: Genova Diagnostics
! http://www.gdx.net/home/
! Microbiology test
! Evaluates for presence of friendly bacteria, pathogenic or
potentially-pathogenic bacteria, yeast.
! If pathogen is detected, lab performs susceptibility testing
against common pharmaceuticals and herbs.
! Parasitology test
! Evaluates for presence of all of above plus parasites
Otitis Media -
! Treatment
! Treat according to findings of test
! If pathogen is detected, treat or refer for prescription
of herbs or pharmaceuticals, depending on degree of
susceptibility to agent and scope of practice in your
state
! Once pathogen is eradicated,
! Use supplement to aid in healing of GI lining:
! Source: Glutagenics by Metagenics
! Dosage: 1/2 tsp tid for 3 weeks
! Supplement with probiotics/prebiotics as discussed
previously for at least 3-6 weeks.
! If no pathogens are detected, but friendly flora is
low, supplement with probiotics/prebiotics as above.
Otitis Media -
! Food Intolerances/Allergies
! Can lead to state of chronic inflammation
! Can lead to OM by creating chronic adenoid inflammation
which can prevent drainage through ET by occluding os
! Often secondary to GI dysbiosis and resultant leaky gut
syndrome; once GI tract is healed, food allergies often
resolve
Otitis Media -
! Food Intolerances/Allergies
! Diagnose via:
! Blood test:
! Often inaccurate in young children
! Often have high level of false positives
! Elimination diet: eliminate most common offenders
for several weeks; assuming symptoms have cleared,
add foods back in one at a time while evaluating for
re-appearance of symptoms
! Can be difficult for family
! Child may be allergic to combination of foods which is
difficult to detect by this method
Otitis Media -
! Environmental allergies and biochemical stressors
! All can lead to chronic adenoid inflammation which can
block os of ET
! Examples include cigarette smoke, pets, household
cleaning agents, laundry products, etc.
! Removal of offender from childs environment results in
decreased inflammation
13
Otitis Media -
! Nutritional Deficiencies
! Common due to Standard American Diet
(SAD)
! Dominated by simple carbohydrates, empty calories,
high sugar, unhealthy fats and little protein
! Most items highly processed which strips foods of
vital nutrients
! Added chemicals (including hormones, antibiotics)
and preservatives make foods less expensive, look
prettier or have a longer shelf life
! Eventually leads to weakened immune system,
obesity and diabetes
! Chronic chemical ingestion often leads to state of
chronic inflammation
Otitis Media -
! Nutritional Deficiencies
! To counteract SAD:
! Increase unprocessed, fresh, organic foods
! Increase fruits, vegetables, whole grains
! Decrease simple carbohydrates, sodas, juices,
! Avoid chemical additives including food colorings,
preservatives, glutamates (Natural Flavor)
! Buy organic whenever possible
! Implement foundational nutrition protocol
! Elimination of chemicals from diet and addition of
essential nutrients will decrease systemic inflammation
and strengthen immune response.
Asthma
Asthma -
Clinical Rationale
! Most frequent cause of school absenteeism <17 years of age
! Onset usually occurs in 1st 5 years
! Asthma occurs when bronchioles are hyper-reactive causing
reversible obstructive lung disease
! Can be triggered by dust, pollen, animal, stress, exposure to
cold
! Trigger " smooth muscle contraction, increased mucus
secretion, inflammation of mucus membranes " increased
airway resistance " expiratory wheeze and prolonged
expiration
! Smooth muscle contraction controlled by balance of
sympathetic and parasympathetic nervous systems
Asthma -
Clinical Rationale
! Subluxation can " abnormal tone in smooth muscle around
bronchiole, can " decreased airway diameter
! Can predispose child to asthmatic attack following exposure to a trigger
! Subluxation can " abnormal biomechanics in chest wall
components " decreased expansion of chest during inspiration
! Decreases oxygenation
! Forces overuse and spasm of secondary muscles of respiration,
including trapezius, anterior scalenes, sternocleidomastoid and pectoral
muscles
! CMT " widened bronchiole diameter, moving child further
away from threshold of asthmatic attack
! CMT " increased respiratory volume and decreased
respiratory effort " improved tissue oxygenation and reduced
overuse of secondary muscles of respiration
Asthma -
State of Research
! 4 randomized clinical trials, 3 cohort studies, 1 crossover
investigation & 4 cases involving 550 patients
! Results mixed
! No improvements in lung function detectable (Bronfort 2002, Balon
1998), but improved quality of life scores and decreased medication
use seen (Bronfort 2002)
! Case reports and case studies showed positive clinical effect of spinal
manipulation for asthmatic children (Nilsson 1988, Beyeler 1965)
! The largest randomized clinical trial to date comparing
different manipulative techniques in the management of
asthma is currently underway by Ali et al in Australia.
Preliminary results show manipulation decreases cortisol and
increases immunoglobulin A levels (Ali 2002).
(See references next slides)
14
Asthma -
Research References
! Ali S, Hayek R, Holland R, McKelvey S-E, Boyce K. Effect of chiropractic
treatment on the endocrine and immune system in asthmatic patients. Proceedings
of the 2002 International Conference on Spinal Manipulation, Toronto, Ontario,
CANADA, October 4-5, 2002, pp. 57-58.
! Balon J, Aker PD, Crowther ER, Danielson C, Cox PG, O'Shaugnessy D, Walker
C, Goldsmith CH, Duku E, Sears MR. A comparison of active and simulated
chiropractic manipulation as adjunctive treatment for childhood asthma. New
England Journal of Medicine 1998; 339(15): 1013-1020.
! Beyeler W. Experiences in the management of asthma. Annals of the Swiss
Chiropractic Association 1965;3: 111-117.
! Bockenhauer Se, Julliard KN, Lo KS, Huang KE, Sheth AM. Quantifiable effects
of osteopathic manipulative techniques on patients with chronic asthma. Journal of
the American Osteopathic Association 2002;102(7): 371-375.
! Bronfort G, Evans RL, Kubic P, Filkin P. Chronic pediatric asthma and chiropractic
spinal maniulation: A prospective clinical series and randomized clinical pilot
study. Journal of Manipulative and Physiological Therapeutics 2002; 24(6): 369-
377.
Asthma -
Research References
! Dhami MSI, DeBoer KF. Systemic effects of spinal lesions. In Haldeman S [ed],
Principles and Practice of Chiropractic, 2nd Edition. Norwalk, CT: Appleton &
Lange, 1992, pp. 115-135.
! Garde R. Asthma and chiropractic. Chiropractic Pediatrics 1994; 1: 9-16.
! Guiney PA, Chou R, Vianna A, Lovenheim J. Effects of osteopathic manipulative
treatment on pediatric patients with asthma: A randomized controlled trial. Journal
of the American Osteopathic Association 2005; 105: 7-12.
! Hunt J. Upper cervical chiropractic care of a pediatric patient with asthma: A case
study. Journal of Clinical Chiropractic Pediatrics 2000; 1: 3-9.
! Jamison JR. Asthma in a chiropractic clinic: A pilot study. Journal of the Australian
Chiropractic Association 1986; 16: 138-144.
! Killinger LZ. Chiropractic care in the treatment of asthma. Palmer Journal of
Research 1995; 2: 74-77.
Asthma -
Research References
! Lines D. A wholistic approach to the treatment of bronchial asthma in a
chiropractic practice. Chiropractic Journal of Australia 1993; 23: 408.
! Nilsson N, Christiansen B. Prognostic factors in bronchial asthma in chiropractic
practice. Journal of the Australian Chiropractic Association 1988; 18: 85-87.
! Nilsson NH, Bronfort G, Bendix T, Madsen F, Weeke B. Chronic asthma and
chiropractic spinal manipulation: A randomized clinical trial. Journal of Clinical
and Experimental Allergy 1995; 25(1): 80-88.
! Nilsson N, Christiansen B. Prognostic factors in bronchial asthma in chiropractic
practice. Journal of the Australian Chiropractic Association 1998; 18: 85-87.
! Peet JB, Marko SK, Piekarczyk W. Chiropractic response in the pediatric patient
with asthma: A pilot study. Chiropractic Pediatrics 1995; 1: 9-13.
! Peet JB. Case study: Eight year old female with chronic asthma. Chiropractic
Pediatrics 1997; 3: 9-12.
Asthma -
Treatment Tools
! Full spine CMT (especially T & costal regions)
! Gonstead said:
! wet lungs: vagus nerve - look at atlas
! dry lungs - sympathetics - look at T spine
! CST (especially respiratory and thoracic inlet diaphragms)
! Deep breathing exercises to increase lung capacity
(ex> blow up a large balloon)
! Strengthen nutritional status to strengthen immune
response - foundational nutrition, diet, etc.
! Uncover and reduce stressors - triggers, stress of life,
food sensitivities
Asthma -
Treatment Protocols
! Tx 2-3x per week for 4 weeks
! Have parent keep diary of # daily episodes,
medications needed, severity of attacks
! If improvement in spine, but no improvement
in symptoms, look for other cause (allergens,
toxicity, etc.)
! Write up a case report with your results
Congenital Torticollis (CTC)
15
Congenital Torticollis -
Clinical Rationale
! Definition: lateral flexion combined with
contralateral rotation of head
! 2 most common causes of CTC:
! Birth trauma " tearing of SCM " pseudotumor
! Appears about 2 weeks of age
! Birth trauma " upper cervical subluxation
! Present at birth; more common in breech presentations
! Can lead to plagiocephaly if left untreated
Significant Points
! DDX list:
! Pseudotumor 2 trauma in SCM muscle
! Upper cervical subluxation
! Spinal cord tumor: visible on plain film x-ray 50% of time
! Vertebral dislocation: secondary to birth trauma
! Vertebral anomaly: hemivertebra, klippel-feil syndrome
! X-ray evaluation of cervical spine
! Perform if no pseudotumor is present
! Will r/o spinal cord tumor, vertebral dislocation, spinal anomaly
! 20% of neonates with CT also have congenital hip
dysplasia
! Be sure to do thorough hip examination (incl. Ortilani & Barlow tests)
State of Research
! Case studies only at this time
! All report success using chiropractic care to
address CT in the absence of pathology
(see references next slide)
State of Research
! Aker PS, Cassidy D. Torticollis in infants and children: a report of three
cases. J Can Chiro Assoc 1990;34(1):13-19.
! Bolton PS. Torticollis: a review of etiology, pathology, diagnosis, and
treatment. J Manipulative Physiol Ther 1985;8(1):29-32.
! Colin N. Congenital muscular torticollis: a review, case study, and proposed
protocol for chiropractic management. Top Clin Chiro 1998;5(3):27-33.
! Fallon JM, Fysh PN. Chiropractic care of the newborn with congenital
torticollis. J Clin Chiro Peds 1997;2(1):116-125.
! McCoy Moore T, Pfiffner TJ. Pediatric traumatic torticollis: a case report.
J Clin Chiro Ped. 1997;2(2):145-149.
! Smith-Nguyen EJ. Two approaches to muscular torticollis. J Clin Chiro Ped.
2004;6(2):387-393.
Treatment Tools
! CMT
! As indicated by examination
! CST
! As indicated by examination
! STM
! Especially to SCM if pseudotumor present
! Rehabilitation exercises (incl. home care)
! Stretching and strengthening exercises (usually positional) away from
tilt and rotation
! Beneficial to work with a PT for this
! Parent education
! Parents should encourage movement in restricted directions and
perform daily stretching/strengthening exercises
Treatment Protocols
! If 2 to SCM trauma:
! 2x per week for 2 weeks and re-evaluate.
! If no pseudotumor is present:
! Further evaluation: x-rays of cervical spine
! If negative for spinal cord tumor, spinal trauma and anomaly, treat
as an upper cervical subluxation
! 2x per week for 2 weeks and re-evaluate
! If no response after 2 weeks, MRI to r/o 50% of
spinal cord tumors not visible on x-ray
16
Making an Office Child-friendly
! Don't focus on pain relief
! Hire a receptionist who likes
children
! Have a little person's coat
rack
! Create a children's area in
your reception room
! Keep a small toy bin in each
treatment room
! Have a stuffed animal in
each treatment room
! Decorate treatment rooms
with childrens dcor
! Take pictures of you and
your pediatric patients and
display photos in reception
area
! Get down to child's level
! EDUCATE, EDUCATE,
EDUCATE!!
How to See More Children in
Your Practice
! Ask patients who are parents to bring their child in for checkup
! Find pregnant patients - speak to birthing or prenatal exercise
classes
! Speak to Moms groups
! Speak to support organizations for pediatric conditions -
ex>allergy, asthma, etc.
! Sponsor an athletic team
! Network with pediatricians and other health care professionals
! Have a booth at a children's fair
! Volunteer at a children's service organization
! Have your own children
How to Learn More About
Pediatrics
! ACA Council on Chiropractic Pediatrics (ACA CCP)
! www.acapedscouncil.org
! ICA Council on Chiropractic Pediatrics (ICA CCP)
! www.icapediatrics.com
! Annual ACA CCP Symposium on Chiropractic and
Pediatrics
! St. Louis in October 30-31, 2009
! Super conference in combination with 3 other ACA Councils
! Annual ICA CCP Conference on Chiropractic Pediatrics
! Colorado Springs, date unknown
How to Learn More About
Pediatrics
! Subscribe to Journal of Clinical Chiropractic Pediatrics
! Available through ICA CCP
! Only peer-reviewed journal in chiropractic pediatrics
! Upledger Institute for Craniosacral training
! 1-800-233-5880
! Diplomate program: DICCP (Diplomate In Clinical
Chiropractic Pediatrics)
! Overseen by independent board ICCP (Intl College of
Chiropractic Pediatrics)
! Recognized by both ACA and ICA

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Pediatrics for the Chiropractor: Spinal

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