Journal of Clinical Chiropractic Pediatrics 2014 (Mar); 14 (2) ~ FULL TEXT
Lauren M. Fry, BAppSc (CompMed-Chiro), MClinChiro
Lauren M. Fry, BAppSc(CompMed-Chiro), MClinChiro,
Elwood, Victoria, Australia
Objective: Breastfeeding an infant has many long and short-term health benefits. Chiropractic care, as part of a multidisciplinary team, has the potential to assist with biomechanical causes of breastfeeding dysfunction. The purpose of this study was to review the literature and explore what evidence there is to support this theory.
Methods: Database searches were performed (PubMed, MEDLINE, Cumulative Index to Nursing and Allied Health and Index to Chiropractic Literature) and hand searches to identify relevant studies. Inclusion criteria were: written in the English language in a peer-reviewed journal, involving infant human participants and a focus on chiropractic treatment for breastfeeding (dysfunction).
Results: Ten articles were reviewed; 5 case studies, 3 case series, 1 clinical trial and 1 narrative.
Conclusions: Limited evidence exists to support chiropractic treatment for infants with breastfeeding dysfunction. Of the 6 case studies, 3 case series and 1 clinical trial found in this report there was a trend towards resolution of breastfeeding issues with chiropractic treatment of biomechanical imbalances. More meticulous, higher evidence studies are needed to provide further evidence of this.
Key Words: breastfeeding, chiropractic, infant, spinal manipulation.
From the Full-Text Article:
Breastfeeding, particularly exclusively for the first 6 months, has been associated with numerous beneficial short and long term health outcomes for an infant. [1, 2] Breast milk has been shown to contain secretory IgA antibodies, lactoferrin, oligosaccharides, numerous cytokines and growth factors which all aid in an infant’s immune response. [3, 4] Purported short term benefits to the infant are a decreased risk of many childhood illnesses.  Incidence of gastro-intestinal infections, otitis media, other respiratory tract infections and asthma, even in those with a strong family history, may be decreased in infants who are breastfed. [6, 7]
The benefits of breast milk extend into later life with extensive literature to support a decreased incidence of type 2 diabetes and obesity in older children and adults who were breast fed as infants. [6, 8-11] The effect appears to be time dependent; the longer breastfed, the more reduced the likelihood of disproportionate weight later in life. [11, 12] The World Health Organization, as well as many other leading authorities, recommend exclusive breastfeeding until the age of 6 months, at which time timely solids can be introduced (with complimentary breastfeeds to at least 12 months). 
In Australia, 92% of women are initiating breastfeeding at birth, yet only 56% are exclusively breastfeeding at 3 months and only 14% at 6 months.  Reasons for breastfeeding cessation are numerous and include environmental and socioeconomic factors.  Others are infant/mother related and include sore nipples, inadequate milk supply, infant having difficulties feeding and a perception that infant wasn’t satiated. [16-18]
The mechanics of breastfeeding from an infant perspective are well documented in the literature. [19-21] Amongst other factors successful breastfeeding relies on a series of complex movements facilitated by the craniofacial musculoskeletal anatomy. [20, 21] Imbalances or asymmetries in this delicate system have the potential to alter an infant’s suck and could possibly lead to nipple pain, breast engorgement, mastitis and insufficient milk supply. 
The purpose of this study was to investigate the available evidence to support the role chiropractic may play in treating breastfeeding dysfunction. At present there has not been a review of the literature to explore this.
Sources of information
Relevant studies were uncovered via the following electronic databases: PubMed, MEDLINE (ProQuest), Cumulative Index to Nursing and Allied Health (CINAHL) and Index to Chiropractic Literature (ICL). Databases were searched from inception through December 2013 using the search terms delineated below. A hand search of appropriate journals and the reference list of each relevant study was then performed to identify any suitable studies missed by the electronic searches.
Search terms and delimiting
Search keywords for all databases included: breastfeeding and the similar breast-feeding and breast feeding, chiropractic and spinal manipulation.
Selection criteria employed
All study designs were included and there was no restriction in terms of age of publication. Only articles published in the English language in a peer-reviewed journal, involving infant human participants and focused on chiropractic treatment for breastfeeding (dysfunction) were included.
A literature search of PubMed using the above stated search terms returned 6 results, 4 of which were not relevant. Of the 2 included, 1 was a case series,  and the other a case study.  The MEDLINE search produced 7 results, only two of which were appropriate, both having been found previously in the PubMed search. [23, 24] The CINAHL search unearthed 7 findings, 4 of which were irrelevant to this study. The 3 found relevant were 2 case series [23, 25] and one case study.  Only one of the case series had turned up in the previous searches. The ICL search produced 14 results, 11 of which appeared relevant and 7 that hadn’t been produced in previous searches. Of those 7, 4 were case studies, [27-30] one was a case series,  another was a clinical trial  and finally, a narrative on collaborative care.  One of these case studies was later not included as it appeared in a journal that was not peer reviewed.  A hand search of each relevant study was performed to identify only one article missed by the electronic investigation.  It too was later not included as it involved an infant with feeding problems assisted by chiropractic care who had only been bottle fed and never breastfed. Relevant journals were also hand searched, to reveal one, previously undiscovered narrative review and case report. 
In summary a thorough literature search revealed only 5 case studies, [24, 26-29] 3 case series, [23, 25, 31,] 1 clinical trial , 1 narrative  and 1 narrative review and case report  that fit the selection criteria of this study.
There is a lack of literature available on the effects chiropractic care may have on breastfeeding dysfunction. That which is available comes from case studies, case series and one low level clinical trial all of which are based on clinical experiences or possibly anecdotal evidence. The findings of these studies have been summarized in Table 1.
NOTE: Click on these tables to increase their size.
Table 1. Part A
(95% confidence intervals) between mean
changes in Oswestry scores*
Table 1. Part B
All 5 case studies [24, 26-29] describe findings of biomechanical change to the upper cervical spine, specifically the atlas or atlantoccipital joint. Holleman  and Bernard  both described cranial restrictions and temperomandibular joint (TMJ) restriction and TMJ asymmetry in mandible with hypertonicity of TMJ musculature respectively. Bernard , Cuhel  and Willis  reported on infants who had difficulty or refused to feed form on particular breast. All cases accounted eventual improvement in infant’s breastfeeding ability and resolution of breast side preference and biomechanical changes.
The narrative review and case report produced by Lavigne  explores the case of a 3-week-old neonate, presenting to a chiropractor with feeding difficulties due to biomechanical dysfunction of upper cervical spine, TMJ and cranial bones complicated by ankyloglossia (tongue-tie). Lavigne also performed a review to investigate the literature available surrounding alleviation of breastfeeding dysfunction following the frenotomy procedure. In this case a medically performed frenotomy along with conservative chiropractic treatment for the musculoskeletal imbalances saw a marked improvement in breastfeeding difficulties.
Hewitt’s study  is titled ‘a case series’, but is however structured as a case report describing two separate cases. Case one denotes an 8-year-old child with cranial restrictions only and case two a 4-week-old male with cranial restrictions as well as biomechanical changes at C1/C2. Hewitt  reported complete resolution of symptoms after a period of chiropractic care.
A pilot case series was performed by Stewart , who administered a questionnaire to 19 breastfeeding mothers pre and post chiropractic care of their infant. Stewart attempted to correlate specific clinical findings (chiropractic subluxations) with specific infant feeding problems. The questionnaire covered the following components of breastfeeding behavior: attachment, extension/arching of infant, side shaking once attached, side preference and overall stress while feeding. Stewart reported a reduction in each category after chiropractic treatment.
Miller et.al.  produced a case series of 114 infants referred to a chiropractor by a medical practitioner for feeding difficulties. The most common clinical findings were posterior cervical joint restriction (88.7%), TMJ imbalance (35.7%) and inadequate suck reflex (34%). Intervention comprised of 2-5 treatments of chiropractic therapy over a 2 week period. The specific outcome desired was exclusive breastfeeding (which none of the infants were achieving prior to treatment). Miller  found that all infants showed some improvement with 78% being able to achieve exclusive breastfeeding at the end of the two weeks.
Vallone  performed a small clinical trial, comparing the craniofacial and spinal biomechanical characteristics of 25 infants demonstrating breastfeeding difficulty with those of 10 infants with no apparent breastfeeding issues. The 25 infants with breastfeeding difficulty demonstrated imbalanced musculoskeletal action as compared to the infants in the control group. Utilization of soft tissue therapies and chiropractic treatment to the spine and cranium resulted in improved feeding in 80% of the affected infants.
Limited evidence exists to support chiropractic treatment for infants with breastfeeding dysfunction. Of the 6 case studies, 3 case series and 1 clinical trial found in this report there was a trend towards resolution of breastfeeding issues with chiropractic treatment of biomechanical imbalances. More studies are needed to provide further evidence of this.
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