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Chiropractic Care for Children
Anne
CC Lee, BSE; Dawn H. Li, MD; Kathi J.
Kemper, MD, MPH
Arch Pediatr Adolesc Med. 2000;154:401-407.
ABSTRACT
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Objective To describe the practice
characteristics and pediatric care of chiropractors.
Study Design Cross-sectional, descriptive
survey.
Setting Chiropractic practices in the Boston, Mass,
metropolitan area.
Participants One hundred fifty licensed
chiropractors.
Main Outcome Measures Demographics, practice
characteristics, and fee structure. Practitioners were
also asked about their approach to childhood
immunizations and a clinical scenario. Data were analyzed
using simple descriptive statistics.
Results Ninety (60%) chiropractors responded. All
were white and 65% were men. Respondents had on average
122 patient visits weekly, of which 13 (11%) were from
children and adolescents. Typical visit frequency ranged
from 1 to 3 times weekly. Average visit fees were $82 and
$38 (initial and follow-up) and 49% of the fees were
covered by insurance. Seventy percent of the respondents
recommended herbs and dietary supplements. For pediatric
care, 30% reported actively recommending childhood
immunizations; presented with a hypothetical 2-week-old
neonate with a fever, 17% would treat the patient
themselves rather than immediately refer the patient to a
doctor of medicine, doctor of osteopathy, or an emergency
facility.
Conclusions Children and adolescents constitute a
substantial number of patients in chiropractics. An
estimated 420,000 pediatric chiropractic visits were made
in the Boston metropolitan area in 1998, costing
approximately $14 million. Pediatric chiropractic care is
often inconsistent with recommended medical guidelines.
National studies are needed to assess the safety,
efficacy, and cost of chiropractic care for
children.
INTRODUCTION
IN 1997,
patients in the United States visited more practitioners
of complementary and alternative medicine (CAM) than all
US primary care physicians.1
Doctors of chiropractic (DCs) are the most frequently
consulted CAM providers and are licensed in all 50
states.1
Chiropractic care is reimbursed by Medicare, and 45 of 50
states mandate that major insurers provide chiropractic
benefits.2-3
An estimated 11% to 16% of Americans visited DCs in
1997.1,
4-5
There are more than 50 000 licensed DCs in the United
States, and the number is expected to double by 2010.6
For many families in the United States, chiropractic care
is no longer an alternative, but an integral part of
regular health care, both for health promotion and the
treatment of common diseases.
Family chiropractic care (including patients ranging from
neonates to the elderly) became widespread in the early
1990s, as DCs began to hold community screenings and
offer chiropractic workshops at public schools.7-8
The concept of pediatric chiropractic care gained
increasing popularity through national campaigns aimed at
"drawing more children and infants into practices for
basic health care."8
Advertisements flourished in major national newspapers.
Organizations such as the International Chiropractors
Association (ICA), Arlington, Va, introduced workshops on
pediatric chiropractic care.9
Several chiropractic colleges incorporated pediatric
courses into their curriculum and offered postgraduate
seminars to educate DCs in pediatric care.
Considerable numbers of children and adolescents seek
chiropractic care. Children made an estimated 20 million
visits to DCs in 1993.10
According to a 1994 survey,11
DCs were the alternative practitioners most often
consulted by pediatric patients. Although most adults
(85%) consult DCs for musculoskeletal conditions,
children frequently visit DCs for respiratory problems,
ear, nose, and throat problems, and general preventive
care.11-12
Common pediatric conditions treated by DCs include otitis
media, asthma, allergies, infantile colic, and enuresis.
However, randomized controlled clinical trials of
chiropractic care for pediatric conditions are rare. One
of the first such trials reported that chiropractic care
offered no significant benefits for pediatric patients
with asthma.13
A complex and historical schism exists within the
chiropractic profession—the opposing groups being the
"straights" and the "mixers."3,
14
The straights rely primarily on chiropractic adjustments
to promote health.3,
14
They believe that vertebral subluxations disrupt spinal
nerves and can lead to a wide array of functional
problems, and that chiropractic care corrects
subluxations, maximizes the body's self-healing
capabilities, and is vital to optimum health.9
The straights are well represented in the ICA, which is a
small but vocal organization (comprising 5% to 10% of all
DCs in the United States9)
known for its promotion of pediatric chiropractic care
and opposition to mandatory immunizations. In contrast,
the mixers use a broader range of diagnostic tools and
therapies, such as laboratory tests, advanced imaging
procedures (magnetic resonance imaging and computed
tomography), nutritional supplements, and herbal
remedies. They make more limited claims about their scope
of practice and often restrict their practices to adults
or to specific conditions, such as lower back pain.3,
14-15
Mixers are generally well represented in the American
Chiropractic Association (ACA), Arlington, which holds the
highest national membership (25%).3,
14
With the growing number of DCs targeting pediatric
populations, it is possible that families will ask
pediatricians about chiropractic care and referring and
coordinating patient services with DCs. To respond in a
knowledgeable manner, pediatricians must have basic
information about the practices and pediatric care of
DCs. We sought to describe chiropractic care in our
metropolitan area for (1) practice patterns, including
visit length, frequency, fees, and insurance
reimbursement; (2) pediatric care, including training,
techniques, specialization, and clinical judgment; and
(3) peer recommendation of pediatric providers.
SUBJECTS AND METHODS
SAMPLE
We performed a cross-sectional survey of DCs in the greater
Boston metropolitan area (Boston Primary Metropolitan
Statistical Area, as defined by the National Census
Bureau) from July to November 1998. Six data sources were
used to identify DCs for the study: the greater Boston
area yellow pages, the Commonwealth of Massachusetts
Board of Registration in Medicine (Boston), the ICA
membership list, ACA practitioner referral list, International
Chiropractic Pediatric Association (Stone Mountain, Ga),
and the Council on Chiropractic Pediatrics (Arlington).
Figure
1 depicts the number of providers identified from the
aforementioned sources.
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| Identification of chiropractors in the
Boston metropolitan area. ICA indicates
International Chiropractors Association; ACA,
American Chiropractic Association; ICA-CP, ICA's
Council on Chiropractic Pediatrics; and ICPA,
International Chiropractic Pediatric Association.
This Venn diagram depicts the chiropractors
identified in the Boston Primary Metropolitan
Statistical Area (defined by the National Census
Bureau). Six hundred fifty-eight doctors of
chiropractic (DCs) were listed by the
Massachusetts Licensing Board, Boston. Of this
group, 350 were listed in the greater Boston area
yellow pages, of whom 19 held single memberships
in the ACA, 18 in the ICA, and 2 in the ICPA. The
remaining overlapping areas within the greater
Boston area yellow pages' circle represent DCs
with more than 1 society membership. The ICA-CP
had a total of 9 members. There were 303 DCs with
no society affiliations. Of the DCs not listed in
the greater Boston area yellow pages, 24 held
single memberships in the ACA, 31 in the ICA, and
7 in the ICPA. The remaining overlapping
memberships are labeled.
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Of the 658 Boston DCs listed in these sources, we selected
160 chiropractic practices. To focus on those DCs most
likely to treat children, all DCs belonging to pediatric
societies (n=20) and all practices with the name "family"
(n=40) were selected. We excluded practices with the
words "pain," "back," and "injury" in their practice name
(n=13). The remaining DCs (n=100) were chosen by computer
randomization from society, licensing board, and greater
Boston area yellow pages listings.
The survey was pilot-tested by telephone on 20 DCs. Minor
revisions were made, and the remaining 140 chiropractic
practices were mailed surveys in July 1998. Six weeks
after the initial mailing, nonrespondents were called for
follow-up; 10 weeks after the initial mailing,
nonrespondents received second surveys.
Of the initial 160 chiropractic practices surveyed, 10
addresses were nondeliverable, yielding a final sample
size of 150. Ninety DCs completed the survey for a
response rate of 60%. We attempted to reach all
nonrespondents by telephone; reasons for nonresponse
included lack of interest in the study, little experience
with children, and being "too busy."
SURVEY CONTENT
The survey was based on questions from the National
Ambulatory Medical Care Survey from the National Center
for Health Statistics (Hyattsville, Md) and was developed
in collaboration with a licensed DC. The survey was 4
pages long and required approximately 15 minutes to
complete. Demographic items included age, race, sex,
educational degrees, year of graduation from chiropractic
school, year of licensing in Massachusetts, and membership
in professional societies. Questions about practice
characteristics included solo vs group practice, number
of patients seen per week, length of initial and
follow-up visits, and frequency of visits. Fee and
insurance issues were addressed in questions about
initial and follow-up visit fees, the proportion of fees
covered by fee-for-service insurance, the use of a sliding
scale, and acceptance of Medicaid patients. Doctors of
chiropractic were asked about the scope and content of
their practice, chiropractic techniques commonly used,
use of radiographic examinations and other laboratory
tests, and prescription of dietary supplements (herbs and
vitamins).
Pediatric care was investigated in questions about specific
training in pediatrics, length of pediatric training,
pediatric patient load (patients per week), and
techniques used for children. The pediatric and
adolescent population was defined using the American
Academy of Pediatrics' (Elk Grove Village, Ill) guidelines
for patients younger than 21 years. Three questions were
included to assess practitioners' beliefs and clinical
judgment about pediatric care. Doctors of chiropractic
were asked (1) whether they recommended childhood
immunizations; (2) how many times they would see a
patient before deciding chiropractic care might not be
helping a condition; and (3) what actions they would
immediately take if presented with a 2-week-old neonate
with a temperature of 38.4°C. For the third question,
respondents were given the choices of referring the
patient to a doctor of medicine or doctor of osteopathy,
taking more history, treating the patient, or filling in
a blank section with their own response.
Finally, DCs were asked to recommend up to 5 DCs other than
themselves for treating children. This question was aimed
at developing a list of peer-recommended pediatric DCs in
our geographic area.
STATISTICAL ANALYSIS
All data were entered into database software (Microsoft
Access; Microsoft Corporation, Redmond, Wash), exported
to a spreadsheet (Excel; Microsoft Corporation), and
analyzed using simple descriptive statistics. Normally
distributed data are reported as averages; nonnormally
distributed data are reported as medians, modes, and
ranges. Because we had no a priori hypotheses and a small
sample size, no post hoc statistical comparisons were
performed.
RESULTS
DEMOGRAPHICS AND TRAINING
All 90 respondents were white and 65% were men. The mean (±
SD) age of the respondents was 40 (±7) years. In addition
to a DC, 88% held a college degree (BA or BS), 4% held a
master's degree, and 2% had obtained a diplomate degree
in pediatric chiropractics (1000 hours of supervised
training). On average, the respondents were graduated in
1986 and were licensed in Massachusetts in 1987.
Forty-one percent of respondents were members of the ACA and
22% belonged to the ICA. Few (4%) reported membership in
both national associations (ACA and ICA). Among our
respondents, members of pediatric associations (the
International Chiropractic Pediatric Association and ICA
Council on Pediatrics) were primarily ICA members
(70%).
PRACTICE CHARACTERISTICS AND FEE
STRUCTURES
Forty-six percent of the respondents were in solo practice.
Of the DCs in group practices, most (55%) practiced with
massage therapists. Twenty-three percent practiced with
other DCs, 15% with acupuncturists, and the remainder
with other clinicians (physical therapists, nurses,
psychiatrists, and others) (Table
1).
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| Table 1. Practice Characteristics of DCs*
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Respondents saw an average of 122 patients per week (range,
15-350). Visit frequency for each patient was typically 1
to 3 times weekly. The mean (±SD) visit length was 52
(±15) minutes for initial visits and 19 (±6) minutes for
follow-up visits; the mean (±SD) charges were $82
(±40) for initial and $38 (±9) for follow-up visits. On
average, 49% of fees were covered by insurance. Forty-two
percent of DCs offered sliding scale fees (including
senior and student discounts), while 47% accepted
Medicaid patients.
SCOPE OF PRACTICE
Doctors of chiropractic reported performing various
diagnostic tests: neurologic examination (77%);
radiographic examination (59%); orthopedic examination
(22%); and laboratory tests (8%). Respondents reported
performing radiographic examinations for an average 55%
of their patients. The main therapeutic technique used
was the spinal adjustment (89%). More than 100 manual
techniques are used by DCs. Techniques used by
respondents were diversified (62%), activator (40%), and
sacrooccipital (37%). Definitions of these techniques are
as follows:
- The diversified technique: one of the most frequently
taught adjusting techniques that draws on several
different sources. It is not based on a specific
analytic system, but uses the normal biomechanics of a
joint to create motion.16
- The activator technique: a technique that uses an
"activator adjusting instrument" that
produces a light discrete torque when triggered.16
- The sacrooccipital technique: a technique based on
the mechanical relationship between the cranium and
pelvis. Padded "blocks" are placed under the patient's
pelvis while the patient is prone or supine; gravity
affects the mechanical relationship between sacrum and
innominates. Upper trapezius muscles are evaluated for
occipital fiber tone.16
Seventy percent of respondents reported recommending herbal
remedies or dietary supplements, and half dispensed them
in their own office.
PEDIATRICS
In 1998, children and adolescents constituted 11% of patient
visits to DCs. On average, respondents had been treating
pediatric patients for 12 years. Two thirds of the
respondents reported training in pediatric medicine.
Pediatric training included pediatric courses in
chiropractic colleges, postgraduate elective courses, or
national conference workshops.
Most DCs (79%) reported modifying their therapeutic
techniques for children. Pediatric techniques included
using light force, using a device called an activator to
deliver gentle torque, performing adjustments on a
child-sized adjustment table or with a child's
head-toggle piece, performing adjustments on the mother's
lap, and familiarizing children with the adjustment by
performing techniques on an animal or doll. Although not
specifically questioned, several DCs reported performing
fewer radiographic examinations on children (n=4) and
charging less for pediatric visits (n=6; mean cost, $28
per visit).
CLINICAL JUDGMENT
When questioned about the number of treatments before
deciding that chiropractic care was not benefiting the
patient or a specific condition, 27% of practitioners
declined to answer. The most common reasons for
nonresponse included (1) that the number of visits would
vary according to the condition and (2) that DCs did not
treat specific diseases, conditions, or symptoms. Doctors
of chiropractic with the second response stated that
their focus is primarily on promoting optimal general
health and disease prevention. Of those who did answer
the question (n=66), respondents reported an average of 7
visits before deciding that chiropractic was not
benefiting the patient.
Thirty percent of respondents reported actively recommending
childhood immunizations; 7% reported recommending against
immunization. The remainder (63%) reported that they did
not make any recommendations or that they educated
parents to allow them to make informed decisions.
Of the 81 DCs who responded to the question about the
neonate with a fever, 68% said they would refer the
patient directly to a doctor of medicine or doctor of
osteopathy, 17% would perform a spinal adjustment, and
15% would take more history or perform further physical
examination.
PEER-RECOMMENDED PEDIATRIC DCs
Of the 658 DCs in the Boston area, 11 (1) were recommended
by at least 3 respondents other than themselves, (2)
cared for at least 9 pediatric patients per week, and (3)
were willing to collaborate with Children's Hospital.
These DCs will be referred to as the peer-recommended
pediatric DCs. Almost all in this group received
pediatric training (10 vs 57 [91% vs 63%]). Forty-five
percent were members of the International Chiropractic
Pediatric Association. Fees and visit lengths of the
peer-recommended pediatric DCs were similar to the other
respondents (Table
2).
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| Table 2. Practice Characteristics of
Peer-Recommended Pediatric DCs*
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Fewer of the peer-recommended pediatric DCs prescribed
herbal or nutritional supplements (36% vs 72% of the
others) and dispensed herbs in their office (18% vs 50%
of the others). Children and adolescents constituted 18%
of their weekly visits. Of the 8 responding to the
clinical scenario of the neonate with a fever, 3 (38%)
said they would perform a chiropractic adjustment and 3
(38%) said they would refer the neonate directly to a physician
or emergency room. Only 1 reported actively recommending
childhood immunizations.
COMMENT
This study
focused on questions pediatricians might ask about DCs in
their communities, identifying DCs in a region, and
characterizing their practice patterns, fees, and
pediatric care.
The demographic and practice characteristics of Boston-area
DCs were similar to those seen nationally in the ACA
Physician Survey,17-18
the National Board of Chiropractic Examiners Survey,19
and other chiropractic surveys.20-21
For example, the median age of our respondents (40 years)
and number of weekly patient visits (122 patients per
week) were similar to other studies.17-18,21
The number of children visiting DCs is substantial and is
increasing. In 1993, the ACA reported that 8% of
chiropractic patients were younger than 16 years18;
the National Board of Chiropractic Examiners reported
that 10% were younger than 17 years.19
This amounted to approximately 20 million pediatric
chiropractic visits annually.10
By 1997, the ACA reported that children constituted 10%
of the patients in the chiropractic practice.17-18
Similarly, children and adolescents accounted for 11% of
patient visits to our respondents and 18% of visits to
the peer-recommended pediatric DCs.
Although the proportion of pediatric visits has remained
relatively stable from 1993 to 1997, the number of DCs
has grown substantially. We estimate that 410,000
pediatric chiropractic visits were made in the Boston
metropolitan area in 1997. Extrapolating the data to the
entire nation, approximately 30 million pediatric visits
were made in the United States in 1997, calculated as
follows:
(Average No. of Weekly Patient Visits
[Reported by
Our Respondents]) x (%
of
Pediatric Visits [1997 ACA Data17-18])
x (52 [wk/y]) x
(No. of Chiropractors
in the Region)
While this projection may be affected by regional variations
in practice, there are currently no other current
estimates of the prevalence of pediatric chiropractic
care. Our estimate represents a 50% increase in pediatric
visits over 4 years, reflecting growth in the number of
DCs and a broadening of the field of pediatrics to
include adolescents. The expected doubling of licensed
DCs in the next 10 years22
is likely to lead to additional pediatric visits to
DCs.
Considering the fees and frequency of visits ($82 and $38
for initial and subsequent visits, respectively, 1-3
times per week), the costs of regular chiropractic care
may be substantial. In our sample, 51% of chiropractic
fees were paid out-of-pocket, comparable to reports by
Eisenberg et al1
and Kassak21
of 44.3% and 43%, respectively. Sliding scales were
offered by 42% of our respondents. Medicaid was accepted
by only 47%, despite the existence of mandated coverage
for chiropractic care since 1973. Only 1% of chiropractic
income came from Medicaid in 1997.17
From our estimates of the annual number of pediatric
chiropractic visits and the reported visit fees, $16
million were spent on pediatric chiropractic care in
Boston during the past year; $8 million of this was paid
by families out-of-pocket. In the United States, we
estimate that approximately $1 billion was spent on
pediatric chiropractic care in 1998, with $510 million
paid by families out-of-pocket, calculated as follows:
(No. of Pediatric Chiropractic Visits) x
(Mean Reported
Cost of an Established Patient Visit)
This national projection may also be affected by regional
variations in practice patterns and costs; further health
services research in CAM is needed to document these
trends.
Safety is a major concern in pediatric health care. Doctors
of chiropractic have reported few complications due to
spinal manipulation; estimates of the incidence of
serious neurologic or vertebrobasilar complications in
adults range from 0.3 to 50.0 adverse effects per 1
million adjustments.14,
23
Most serious complications have resulted from cervical
manipulation. Shafrir and Kaufman24
reported a case of quadriplegia resulting from
chiropractic manipulation in a child with spinal cord
astrocytoma. Most of our respondents (80%) modified their
procedures for children to reduce the risks of adverse
effects, although none stated specifically that they
avoided cervical manipulation in children. Another
concern is the safety of repeated radiographic
examinations in children and adolescents.25
A few DCs (n=4) reported ordering fewer or no
radiographic examinations for pediatric patients.
Many pediatricians are concerned that chiropractic care may
delay or prevent appropriate medical diagnoses and
treatment.26-28
The ICA Web site for consumer information states, "The DC
can provide all three levels of primary care
interventions and therefore is a primary care provider,
as are MDs and DOs. . . . The DC's office is a direct
access portal of entry to the full scope of
service."9
On its parent information site, the ICA describes the
benefits of a "conservative, drugless approach to health
care . . . a pleasant experience, one without painful
injections and procedures, but with plenty of
nurturing."9
On the other hand, ICA policy obliges patient referrals
to doctors of medicine or doctors of osteopathy or
emergency facilities when limits of skill or authority
have been reached and in serious conditions such as high
fever and severe pain.9
Presented with a hypothetical case of a 2-week old
neonate with a temperature of 38.4°C), 17% of the
respondent group and 38% of the peer-recommended
pediatric DCs stated that they would treat the child
themselves rather than immediately refer the child to a
doctor of medicine, doctor of osteopathy, or an emergency
facility. These results may be limited because in a real
situation the practitioner might have more information
about the patient, would not choose between 3 exclusive
options, and could reevaluate and question the patient
during an office visit. The question may also have been
interpreted in different ways, (ie, that the hypothetical
patient had already seen a doctor of medicine or doctor of
osteopathy or was concurrently seeing a pediatrician).
Nonetheless, these results may concern pediatricians
considering the adverse consequences of delayed medical
care.
Another issue of concern is the failure to promote childhood
immunization. While the ACA officially states that
"chiropractic manipulation is not a substitute for
routine vaccinations, and our association considers any
contrary suggestion to be unethical, unprofessional, and
wrong,29"
the ICA is opposed to mandatory immunizations and
"supports each individual's right to be made aware of the
possible adverse effects of vaccines upon a human
body."9
One third of American DCs believe that "there is no
scientific proof that immunization prevents disease, that
vaccinations cause more disease than they prevent, and
that contracting an infectious disease is safer than
immunizations"; 81% felt that immunization should be
voluntary.30
Less than one third of DCs responding to this survey
actively recommended childhood immunizations and 7%
recommended against them. The remaining respondents either
did not answer or stated that they educated parents to
allow them to make their own informed decisions. These
issues raise great concern as more and more children and
families seek chiropractic care, particularly if the care
is not coordinated with a pediatrician.
Consumer Reports recently reported the frequent promotion
of dietary supplements and in-office product distribution
as a way of enhancing chiropractic income.7
Almost 75% of our respondents said they recommended
dietary supplements or herbal remedies, with half
distributing the supplements in their office. Fewer of
the peer-recommended pediatric DCs recommended and distributed
nutritional supplements, reflecting the greater influence
of "straight" philosophy on these practitioners. The
clinical therapeutic effects and toxicity of these
products need to be studied in both adults and children.
Additionally, DCs must be evaluated on their education in
nutritional supplementation and herbal therapies to
determine their qualifications to prescribe these
therapies.
Despite the cost, most chiropractic patients report high
levels of satisfaction with the care that they
receive.31-32
Several factors may play a role in patient satisfaction.
The average 19-minute visit to a chiropractor was
slightly longer than the average 14-minute visit to a
pediatrician.33
The holistic philosophy of health and life is often
shared by the practitioner and patient.5
The "laying on of hands," the prompt availability of
appointments, and psychosocial factors such as the DC's
role in "legitimizing the sick"34
are additional contributing factors. The degree of
patient satisfaction among adults can lead to parents desiring
chiropractic care for their children, thus contributing to
the increased demand for pediatric chiropractic
care.
This study has several limitations. First, the survey was
confined to the Boston metropolitan area and needs to be
replicated with a larger national sample. Second, more of
our respondents were members of chiropractic societies
(the ACA or the ICA) than the national average. Our
results may be biased to reflect the views of these
organizations, and therefore may not reflect those of the
general chiropractic community.
Selection bias is another limitation. Because the surveys
required 10 to 20 minutes to complete, busier practices
and those with few pediatric patients were less likely to
respond. We also selected for family chiropractic
practices and members of pediatric organizations (n=60)
and excluded DCs whose practices were limited to back and
neck pain or sports medicine. Therefore, the pediatric
patient load, techniques, and practices of our respondents
might not reflect the entire chiropractic community. On
the other hand, our data describe a subset of
practitioners with particular experience and interest in
pediatric chiropractic care.
Another limitation is that several of the questions about
practice characteristics did not specifically restate the
words "for children" (ie, those on fees, visit frequency,
and frequency of radiographic examinations); therefore,
some reported values may vary for purely pediatric
populations. A few DCs self-reported that they charge
less and order fewer radiographic examinations for
children. Data were also collected by self-report rather
than direct observation. Future studies may include
independent methods to verify key outcomes.
The survey's inquiry about collaboration with Children's
Hospital and peer recommendations may have biased
respondents' answers. Respondents may have been more
likely to either (1) report recommending immunizations
and refer the neonate with a fever to a doctor of
medicine or doctor of osteopathy or (2) omit the question.
It is also possible that respondents may have reported
higher pediatric values with respect to pediatric
training and patient visits.
Finally, we used a broad definition of the general pediatric
and adolescent population (age <21 years) as defined by
the American Academy of Pediatrics, Elk Grove Village,
Ill. Future studies might address the use within
different age groups (ie, infants, school-aged children,
and adolescents). This preliminary survey of
practitioners also did not address patient satisfaction,
efficacy, or adverse effects of chiropractic care. All of
these are crucial outcomes to address in future
studies.
Despite the limitations, to our knowledge this is one of the
first studies to address chiropractic care for children;
it adds vital information to understanding the practices
of the CAM practitioners most frequently consulted by
children in the United States. Approximately 30 million
pediatric visits to DCs are made annually in the United
States, with an estimated total cost of $1 billion and
costs split approximately in half between third-party
payers and families paying directly out-of-pocket. Only
30% of DCs surveyed promoted immunizations, which are proven
cost-effective therapies, yet 70% recommended herbs and
dietary supplements of unknown value. When presented with
a neonate with a fever, 17% of respondents would treat
the child with a chiropractic adjustment rather than
refer the child to a medical doctor. If DCs continue to
provide pediatric and primary care, the medical community
may need to consider different options to enhance and
ensure the quality of this care.
Although pediatricians may be unfamiliar or uncomfortable
with chiropractic care, the fact that families are using
these therapies needs to be acknowledged. If
pediatricians wish to play a central role in coordinating
comprehensive primary care for children, discussion about
pediatric chiropractic care should be facilitated with
patients, parents, and DCs. For example, pediatricians
should inquire about all therapies that patients use for
health promotion and illness, including chiropractic
care, as well as herbal remedies, acupuncture,
meditation, and other CAM therapies. Additional studies
are needed to address the safety and effectiveness of
chiropractic care and other CAM therapies for children, along
with the elements of care that contribute most strongly to
patient satisfaction. Our findings clearly indicate the
necessity of strengthening collaboration and research
between the chiropractic, medical, and public health
communities.
| Editor's Note: When I contemplate a
chiropractor treating a 2-week-old neonate
with a fever, I get a gigantic
backache.—Catherine D. DeAngelis, MD
| |
AUTHOR INFORMATION
|
|
Accepted for publication September 24,
1999.
This work was supported by Harvard Medical School, Office of
Enrichment Programs, Boston, Mass (Dr Lee).
Presented in part at the Pediatric Academic Societies
Meeting, San Francisco, Calif, May 4, 1999.
We thank Charles Berde, MD, PhD, Henry Bernstein, DO, and
Judy Palfrey, MD, for their thoughtful comments on the
manuscript; Eddy Cohen, DC, and Dawn Cohen, DC, for their
helpful input in developing the questionnaire; and Lisa
Kynvi, BA, Ted Kaptchuk, OMD, and the entire Pain
Treatment Service at Children's Hospital, Boston, for
their assistance, encouragement, and support of this
work.
Reprints: Kathi J. Kemper, MD, MPH, Harvard Medical School,
Center for Holistic Pediatric Education and Research,
Children's Hospital, 333 Longwood Ave, LO 547, Boston, MA
02115 (e-mail: kemper_k{at}a1.tch.harvard.edu
).
From the Harvard Medical School, Boston, Mass (Ms Lee and Dr
Kemper); Columbia Medical School, New York, NY (Dr Li); and
Children's Hospital, Boston (Dr Kemper).
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