J Manipulative Physiol Ther 2009 (Oct); 32 (8): 670674 ~ FULL TEXT
Joyce E. Miller, DC, Ann-Kristin Sulesund, Andriy Yevtushenko
Advanced Professional Practice Chiropractic Paediatrics,
Bournemouth University, Bournemouth, UK.
OBJECTIVE: The purpose of this study was to describe the circumstances, clinical features, role, and results of chiropractic management of infants who were referred to a chiropractic clinic for failure to adequately feed at the breast.
METHODS: Clinical case series of 114 infant cases of hospital-diagnosed or lactation consultant diagnosed feeding problems that were treated with chiropractic therapy in addition to routine care and followed to short-term result.
RESULTS: The most common age of referral was 1 week (mean, 3 weeks; range, 2 days-12 weeks), and the most common physical findings were cervical posterior joint dysfunction (89%), temporomandibular joint imbalance (36%), and inadequate suck reflex (34%). Treatment was chiropractic therapy in addition to any support given elsewhere. All children showed some improvement with 78% (N = 89) being able to exclusively breast feed after 2 to 5 treatments within a 2week time period.
CONCLUSIONS: Cooperative multidisciplinary care to support breastfeeding was demonstrated in this population. Chiropractic treatment may be a useful adjunct to routine care given by other professionals in cases of diagnosed breastfeeding problems with a biomechanical component.
From the Full-Text Article:
Nothing is more important to the short and long-term health of the newborn than mother's milk.  All mammals breast feed; almost all do so successfully. Only humans have a high failure rate. Between 12.8% and 44% of infants reportedly experience suboptimal infant breastfeeding (SIB).  Exclusive breastfeeding for the first six months is recommended by the American Academy of Pediatrics, the World Health Organization, and Healthy People 2010. 
Although breastfeeding is the optimal form of nutrition for the infant, mother, and society, formula feeding is sometimes necessary although it has down-sides. One study showed that owing to having more illnesses, formula-fed infants cost the health care system substantial amounts of money in the first year of life.  They found that formula feeding costs between $331 and $475 per infant in doctor's visits the first year. Breastfeeding is an important nutritional and developmental component of infant life, shown to decrease the risk of many childhood illnesses.  Acute otitis media is 50% less likely to occur in children that are breastfed for at least 3 or 6 months.8 Children before the age of 10 years with a family history of asthma are 40% less likely to have asthma if they were breastfed for at least 3 months compared with those who were not breastfed.  Infants who were exclusively breastfed for at least 4 months were 3 times less likely to suffer severe respiratory tract infections, which necessitated hospitalization. 
Risk of sudden infant death syndrome is reduced by 50% if infants are exclusively breastfed according to a large study recently conducted in Germany. 
Breastfeeding has lifelong positive effects. Infants who were breastfed were much less likely to suffer from obesity and type 2 diabetes in adult age. [11, 12] A meta-analysis of 17 studies showed that duration of breastfeeding in infancy was inversely proportional to the risk of being overweight in adult life.12 Each additional month of breastfeeding was associated with a 4% reduction in risk of excessive weight later in life. 
Our aim was to review cases of infants who had been referred to a chiropractic teaching clinic and who demonstrated persistent feeding difficulties and to describe the outcomes following chiropractic care. The united goal set by the mothers and the health professionals was exclusive breastfeeding of the infant.
Although none of the infants were presented specifically for birth trauma, almost 14% had frank signs of birth trauma and it has been proposed that bruising and trauma to the infant's cranium, face and spine during birth can lead to feeding difficulties. [14, 15] Although it is difficult (if not impossible) to precisely establish exact reasons for feeding problems in the infant, assisted births such as forceps, vacuum extraction and cesarean sections have been implicated. For example, vacuum extraction has been shown to be a strong predictor of early cessation of breastfeeding.  In the present case series 10.4% of the experimental group experienced a vacuum extraction delivery compared to the 4.3% average reported for 3 local hospitals. 
Likewise, forceps delivery may exert excess pressure on cranial bones, which may alter symmetry of the cranium and/or jaw causing poor suck function in the baby.  Forceps were used in 19.1% in this population compared to 3.9% in the local hospital averages. 
Because 68% of these infants were first-born, it can be said that this may be linked to the increased likelihood of delivery complications in primaparas as well as being linked to inexperienced mothers who may have a more difficult time with breastfeeding.  Prematurity was not an issue as all infants were born full term.
Infants in this cohort had been seen by various health care practitioners which included one or more of the following: midwife, lactation consultant, pediatrician, general practitioner, feeding consultant and/or chiropractor. Infant feeding is seen as an urgent problem with no single answer. All professionals with skills in this arena are called upon to assist and cooperation is the rule rather than the exception. All of these infants had had pertinent investigations for pathology and extensive training with lactation consultants and/or midwives prior to referral for chiropractic care. Chiropractic skills fit into the realm of manual therapy to treat biomechanical problems. Once the feeding problems were determined not to be pathological, genetic, or maternal in origin, care by a manual therapist was appropriate. The young age of the children who were referred (1 week of age was the mode) may suggest that health care professionals are cognizant of the care, which is available and appropriate and recommend that care for the infant.
Our one specific outcome measure was ability to exclusively breastfeed (with maintenance of weight gain). We did not use any of the common rating instruments as they have not been validated in any controlled manner. [16, 19] Mothers were also given the opportunity to rate the improvement on a 10point scale, so that they could record partial improvement, no improvement or worsening. At first glance, it seems that all of the infants improved somewhat in their ability to breastfeed. However, with exclusive breastfeeding as the primary outcome measure, it was simple to determine an exact success rate but impossible to credit that success to any specific modality of treatment. The degree of improvement that was related to the natural course of the condition as well as the maternal commitment and effort versus how much could be attributed to chiropractic intervention and/or support from lactation consultants cannot be established. Maturity of the infant, healing of injury or the effects of medication wearing off could result in an improvement in feeding without intervention.  That said, no child can be left to flounder whilst waiting for the natural history to take its course.
Not all of the infants graduated to exclusive breastfeeding. This can be seen as failure since exclusive breast feeding is the goal set by the World Health Organization  as well as the clinicians and parents involved. Twenty per cent of the infants (N = 23) had to be bottle-fed which often means with manufactured milk. It has been shown that early introduction of any artificial milk is associated with further decline in the use of mother's milk for the infant. 
There were several limitations, some of which are inherent in a case series. This type of study, by its definition, cannot determine efficacy of the therapy given. A randomized controlled trial is the best way forward to determine conclusively whether manual therapy is a viable option to assist these mother-infant dyads to achieve exclusive breastfeeding.
Another weakness in this study is the lack of long-term follow-up. Exclusive breastfeeding to 6 months of age is recommended by the World Health Organization.  In addition, there were multiple sources of birth information including parental report and hospital records, leaving room for error in data recall. Examination procedures were standard but may have been executed differently by multiple examiners. All infants either were concurrently or had been under care of other professionals, and there was no standardization of their contribution to the treatment of the infant.
Feeding difficulties in an infant are fraught with stress for the infant and the family. All professionals seek to support the mother/infant dyad in successful breastfeeding. There are several case studies, which suggest that a chiropractic approach to this issue may be useful. [14, 2224] This study sought to discover any unique characteristics of infants presenting with breastfeeding problems and whether chiropractic care offered any benefits within the milieu of wider health care. Two points can be highlighted. First, there was a higher than average rate of birth intervention in this cohort, suggesting one possible etiology for a biomechanical problem. Second, given that all of these patients were sent by other health care professionals, there was a recognition that biomechanics may be part of the problem and that a chiropractic approach might be efficacious. Further higher-quality studies are required to determine whether this is the case.
This case series found that in a population of 114 infants referred by a medical practitioner to chiropractors for feeding difficulties, 89 (78%) were exclusively breast fed after 4 treatments. It is not known whether this is a result of chiropractic manual treatment, the cotreatment provided along with other health care providers or the natural course of this condition. Cooperative care may go some way forward to meet the enormous challenge of exclusive breastfeeding as a goal in developed populations where breastfeeding initiation is high but numbers rapidly decline after the first week.
Infants with suboptimal breastfeeding are at higher risk of being artificially fed which may create short and long-term problems for the child, the mother, and society.
Suboptimal infant breastfeeding is recognized early by medical professionals who are in a prime position to refer for adjunctive care in a cooperative effort to solve the problem.
For infants in this study, routine care plus chiropractic care resulted in the ability of 78% of infants to exclusively breastfeed.
Jackson, KM and Nazar, AM.
Breastfeeding, the immune response, and long-term health.
J Am Osteopath Assoc. 2006; 106: 203207
Geddes, DT, Langton, DB, Gollow, I, Jacobs, LA, Hartmann, PE, and Simmer, K.
Frenulotomy for breastfeeding infants with ankyloglossia: effect on milk removal and suckling mechanism as imaged by ultrasound.
Pediatrics. 2008; 122: 188194
National Center for Health Statistics, 2009.
Available at: http://www.cdc.gov/breastfeeding.
American Academy of Pediatrics, Section on Breastfeeding.
Breastfeeding and the use of human milk.
Pediatrics. 2005; 115: 496506
World Health Organization.
Exclusive breastfeeding. (Available at:)
US Department of Health and Human Services,
Public Health Service,
Office of the Assistant Secretary for Health; 2000.
Ball, TM and Wright, AL.
Health care costs of formula-feeding in the first year of life.
Pediatrics. 1999; 103: 870876
Ip, S, Chung, M, Raman, G, Chew, P, Magula, N, DeVine, D, Trikalinos, T, and Lau, J.
Breastfeeding and maternal and infant health outcomes in developed countries.
Evid Rep Technol Assess. 2007; 153: 1186
Bachrach, VR, Schwarz, E, and Bachrach, LR.
Breastfeeding and the risk of hospitalization for respiratory disease in infancy: a meta-analysis.
Arch Pediatr Adolesc Med. 2003; 157: 237243
Vennemann, MM, Bajanowski, T, Brinkmann, B et al.
Does breastfeeding reduce the risk of sudden infant death syndrome?.
Pediatrics. 2009; 123: e406e410
Owen, CG, Martin, RM, Whincup, PH, Davey-Smith, G, and Cook, DG.
Effect of infant feeding on the risk of obesity across the life course: a quantitative review of published evidence.
Pediatrics. 2005; 115: 13671377
Owen, CG, Martin, RM, Whincup, PH, Davey-Smith, G, and Cook, DG.
Does breast feeding influence the risk of type 2 diabetes in later life? A quantitative analysis of the published evidence.
Am J Clin Nutr. 2006; 84: 10431054
Harder, T, Bergmann, R, Kallischnigg, G, and Plagemann, A.
Duration of breastfeeding and risk of overweight: a meta-analysis.
Am J Epidemiol. 2005; 162: 397403
Resolution of Suckling Intolerance in a 6-month-old Chiropractic Patient
J Manipulative Physiol Ther 2000 (Nov); 23 (9): 615618
Impact of birthing practices on the breastfeeding dyad.
J Midwifery Womens Health. 2007; 52: 621630
Hall, RT, Mercer, AM, Teasley, SL, McPherson, DM, Simon, SD, Santos, SR, Meyers, BM, and Hipsh, NE.
A breast-feeding assessment score to evaluate the risk of cessation of breast-feeding by 7-10 days of age.
J Pediatr. 2002; 41: 659664
Birthchoiceuk.com [homepage on the Internet].
Birth Choice UK. Available from:
Dewey, KG, Nommsen-Rivers, LA, Heinig, MJ, and Cohen, RJ.
Risk factors for suboptimal infant breastfeeding behaviour, delayed onset of lactation, and excess neonatal weight loss.
Pediatrics. 2003; 112: 607619
The assessment toll for lingual frenulum function: Use in a lactation consultant private practice.
Pasadena (Calif): Pacific Oaks College; 1993. Thesis.
Infant feeding and analgesia in labour: the evidence is accumulating.
Int Breastfeed J. 2006; 1: 25
Hill, PD, Humenick, SS, Brennan, ML, and Woolley, D.
Does early supplementation affect long-term breastfeeding?.
Clin Pediatr. 1997; : 345350
Chiropractic care for infants with dysfunctional nursing: a case series.
J Clin Chiropr Pediatr. 1999; 4: 241244
Chiropractic evaluation and treatment of musculoskeletal dysfunction in infants demonstrating difficulty breastfeeding.
J Clin Chiropr Pediatr. 2004; 6: 349368
Chiropractic Management of an Infant Experiencing Breastfeeding Difficulties and Colic: A Case Study
J Clinical Chiropractic Pediatrics 2000; 4 (1): 245-247
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