Introduction
Methods
Protocol and registration
Eligibility criteria
Participants
Interventions
Comparators
Outcomes
Mild | Asymptomatic or mild symptoms, requiring self-care only to alleviate symptoms (e.g. ice/heat, over-the-counter analgesic). |
Moderate | Limiting age-appropriate activities of daily living (e.g. work, school) OR sought care from a medical doctor. |
Severe | Medically significant but not immediately life-threatening; temporarily limits self-care (e.g. bathing, dressing, eating); OR urgent or emergency room assessment sought. |
Serious | Results in death OR a life-threatening adverse event OR an adverse event resulting in inpatient hospitalization or prolongation of existing hospitalization for more than 24 h; a persistent or significant incapacity or substantial disruption of the ability to conduct normal life functions. |
Indirect harms | The use of intervention may cause a delay in diagnosis or treatment and the delay itself carries the potential harm. |
Study designs
Information sources
Study selection
Risk of Bias in individual studies
Data items
Data extraction
Randomized Controlled Trialsa | ||||||
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Author(s), Year | Subjects & Setting; n | Interventions; n | Comparisons; n | Follow-up | Outcomes | Key Findings Description Incidence: %, (95% CI) |
Miller et al., 2012 [61] | Infants (< 8 wks), born at gestational age > 37 wks, birth weight > 2500 g, no other conditions or illness, unexplained persistent crying, Anglo-European College of Chiropractic; n = 104 | SMT w/o blinding; n = 33 SMT w/ blinding; n = 35 SMT: low force tactile pressure to spinal joints and paraspinal muscles (estimated at 2 N of force without rotation of the spine), where dysfunction was noted on palpation, pragmatic, individualized to exam findings of the individual; chiropractic manual therapy of the spine | No SMT w/ blinding; n = 34 | 10 days or complete resolution of symptoms (discharged) SMT w/o blinding: 10 day, n = 26; discharged, n = 7 SMT w/ blinding: 10 day, n = 30; discharged, n = 5 No tx w/ blinding: 10 day, n = 22; dropped out, n = 12 | Parent report of any AE during tx period | One child in comparison group reported an AE of increased crying. Incidence of increased crying in comparison group: 2.94% (0.52, 14.92) |
Sawyer et al., 1999 [32] | 6 mos – 6 years, > 3 episodes acute otitis media in last year, middle ear effusion at first 2 visits; Northwestern College of Chiropractic, Bloomington, Minnesota; n = 20 | 10 tx over 4 weeks; n = 9 Full spine HVLA SMT, emphasis on upper cervical area | 10 placebo over 4 weeks; n = 11 Manual static and motion palpation and light touch of specific spinal segments. Identical to active tx without HVLA. | Immediately after completion of tx, 1 month after completion of tx | Direct verbal inquiry at each visit | One parent in tx group reported their child had mid-back soreness after 1 tx which resolved after a few days. Another child was reported to be irritable for a short time after tx. Incidence of AE in the tx group: 22.22% (6.32, 54.74) One parent of a child in the placebo group reported excessive crying after tx. Incidence of AE in the placebo group: 9.09% (1.62, 37.74) RR: 2.44 (0.26, 22.8) |
Author(s), Year | Source Population | Sample Characteristics | Exposure | Outcomes | Confounders | Key Findings |
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Saedt et al., 2018 [33] | Infants < 27 wks, referred w/ indications of upper cervical dysfunction, w/o causative concomitant pathology, potential underlying pathology, &/or red flags; Netherlands | Mean age: 11.2 wks62.3% male Reasons for seeking care: clear positional preference, restlessness and abnormal head position; n = 307 | Mild mobilization techniques focusing on atlas (C1) in relation to C0-C2. Average impulse of 11–20 N. | Harms recorded by manual therapists via questionnaire and physical exam post-exam: Mild: transient side effect lasting < 24 h Moderate: requiring medical and/or general practitioner tx Severe: requiring hospital tx, AE | N/A | Severe: 0% Moderate: 0% Mild: Vegetative responses after mobilization were reported: - Flushing: 17.8% (14.03, 22.59) - Hyper-extension: 4.3% (2.49, 7.11) - Perspiration: 3.6% (2.01, 6.30) - Gastro-esophageal reflux: 0.3% (0.06, 1.82) Short breathing pattern changes: 9.2% (6.39, 12.87) |
Author(s), Year | Subjects & Setting; n | Intervention(s) | Method of Measurement of AE | Follow-up | Key Findingsa |
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Iyer, 2017 [34] | Patient A: 7-month-old; male; difficulty with constipation since birth; Patient B: 7-month-old; male; constipation since birth; n = 2 | Gentle acupressure stimulation on feet, scar tissue mobilization, gentle manipulation was applied to the cervical and lumbar segments and SI joints, with the line of drive being posterior to anterior and lateral to medial (magnitude of thrust and force adapted to patient age and neuromusculoskeletal maturity); patient A also had DNS rehabilitation Patient A: 2x/week, 5 wks Patient B: 2x/week, 4 wks | Cannot say | During course of tx | No adverse reactions were reported to occur with the intervention |
Young, 2017 [56] | Patient A: 26-month-old; female; crying on waking complaining of neck pain; no known previous accidents or injuries during play, played in bouncy house, no complaints of pain the day of; pain increased on 4th day with reduced range of motion and torticollis; Patient B: 33-month-old; male; playing in bouncy house, no complaint of pain or injury, awoke next morning with right-sided neck pain, 1 day later could not turn head to the right; n = 2 | Activator 4 applied at its lowest force setting, ischemic compression to trigger points to patient tolerance, home since and range of motion exercises Patient A: 1 tx Patient B: 4 tx over 2 weeks, with 3 tx including SMT | Cannot say | Patient A: 1 week and 3 years later Patient B: throughout care and 3 years later | No reported adverse consequences to occur with the intervention |
Zhang, 2004 [35] | Children with acute otitis media < 2 mos, < 10 years old, no medical tx; n = 20 | Low force (2–32 oz), Toftness chiropractic adjustment by a metered hand-held pressure applicator at the cervical, thoracic, lumbar and sacral contact site; number of adjustments range from 3 to 6 | Cannot say | During the study period | No side effects or deterioration of clinical presentations were found to occur with the intervention |
Paravicini, 2018 [66] | Male infants; 4.5–15 mos old; diagnosed with arthrogenic newborn torticollis, radiographs demonstrated rotational malposition and translation of atlas on axis in all cases; unresponsive to previous conservative tx methods; n = 6 | Mobilization under anesthesia by doctor of chiropractic and assistant; atlas in full flexion; in cases of subluxated C1–2 articulation, a little traction was added; assistant chiropractor stabilized shoulders of sedated patient; line of drive along almost horizontal joint place with minimal force and no impulse | Cannot say | During the intervention | No AE occurred with the intervention |
Alcantara, 2008 [47] | Patient A: 21-month-old; male; complaint of constipation since birth; Patient B: 7-month-old; female; complaint of constipation since 2 mos; Patient C: 21-month-old; female; encopresis and severe constipation since 10 months old; n = 3 | Patient A: Decreased HVLA type thrusts; Activator technique, 3x/week for 3 weeks, 2x/week for 3 weeks, 1x/week (2 mos of care); dietary changes Patient B: 2x/week for 3 weeks; Activator Patient C: frequency not reported (2 mos of care); HVLA type thrust | Cannot say | Patient B: 1-yr FU, normal bowel movements Patient C: 3-yr FU normal bowel movements | Parents did not report any adverse reactions to occur with the intervention |
Alcantara, 2010 [49] | Patient A: 7-year-old; male; ADHD; Adderall, Zoloft taken during chiropractic care; Patient B: 8-year-old; male; no medications; n = 2 | Patient A: 20 visits over 32 weeks; proEFA supplement Patient B: 49 visits over 24 weeks HVLA type thrusts: diversified and Gonstead techniques | Cannot say | During the course of care | No AE documented/reported by patients or parents to occur with the intervention |
Miller, 2008 [50] | Retrospective review of pediatric cases (patients = 781, total visits = 1310); < 3 years old; Chiropractic college teaching clinic; n = 781 (dismissed no treatment =82); 697 treated & reported outcomes; total visits = 5242 | Patients receiving a type of chiropractic manipulation provided by interns (n = 697) Full spine pediatric SMT; n = 531 Occipital-sacral decompression; n = 50 Cervical spine pediatric SMT; n = 47 Thoracic spine pediatric SMT; n = 11 Lumbar spine pediatric SMT; n = 2 Pelvic pediatric SMT; n = 17 Other: n = 33 | Negative side effects were detected by interpreting parental comments in the FU to the previous tx or same day as tx (n = 697). Defined as any adverse reaction reported by the parent. When an adverse reaction was reported by the parents, a description was detailed. Mild: transient and lasting < 24 h Moderate: requiring medical (general practitioner) tx Severe: requiring hospital tx | During the course of care | Male; 8 weeks old; post first cervical spine SMT tx for infant colic; parents called to report infant was not feeding well and was mildly distressed; following day parents report infant was fine and parents resumed care at the clinic Female; 8 weeks old; post 4th tx of cervical and thoracic SMT for infant colic; mother called to report infant had been crying since the tx; mother later reported the infant slept better than usual and resumed care at the clinic Female; 6 weeks old; few hours post first cervical spine SMT tx, parents reported a “head tilt”; infant was examined and presented with full range of motion and no antalgic posture; care continued Female; 7 weeks old; post first cervical spine SMT for infant colic; mother reported infant cried a lot, slept for 2 h, then awoke and continued to cry; continued for 3 more visits and self-discharged; at FU phone call mother reported infant was “doing fine” and did not require more care Male; 5 weeks old; FU with the parents; reported they would not attend the 7th visit because after the 6th visit of SMT for infant colic, the baby was restless and crying for almost 8 h; they did not continue with tx Male; 17 weeks old; reported birth trauma; on 25th visit immediately post pelvic SMT, infant began to crying, mother felt this was a cry of pain; a corrective ilium adjustment was performed by tutor and the baby stopped crying; mother called later that day to report child was fine; mother continued to bring her child for monitoring and care for next several months Female; 12 weeks old; on 11th visit, cervical spine SMT done for kinematic imbalance due to suboccipital strain, infant cried during tx and continued to cry after returning home; FU next day by phone, mother reported the infant was better but wished to stop tx |
Author(s), Year | Subjects & Setting; n | Intervention(s) | Method of Measurement of AE | Follow-up | Key Findingsa |
---|---|---|---|---|---|
Hubbard, 2010 [62] | 7-year-old; female; migraine HA, mid-back and abdominal pain for previous 2 mos, episodic vomiting for intermittently for 9 mos | 8-week course of low velocity, low-amplitude adjustments, following upper cervical pediatric protocol; 7 tx to C1 over 13 visits. | Cannot say | During course of tx | No report of adverse symptoms occurred after the intervention |
Muir, 2012 [63] | 5-year-old; male; ADHD (no medication): acting out, inability to follow instructions, poor home and school performance | 11 tx over summer, 2-3x/week in November (re-evaluation at 4 wks, 2x/month between December–May); SMT, soft tissue therapy, and myofascial release therapy | Cannot say | 1 year | No AE were reported |
Bourque, 2018 [53] | 5-month-old; male; fussing, irritability, crying, grunting, rigidity, abnormal position of left arm, 2 wks of constipation, breastfeeding difficulties on right side, apparent discomfort lying on stomach; fracture of left clavicle during birth | 1x/week for 2 wks, 2 tx over 2 mos; sacro-occipital technic for occipital restriction, Thoracic spine (T2 and T5) was treated with the “touch and hold” technique by holding a specific, light pressure on the fixated vertebrae. | Cannot say | Patient A: 5 weeks Patient B: 4 weeks | No AE related with the intervention |
Berube, 2004 [57] | 6-day-old; female; symptoms of digestive disorder that began at 4-days-old, difficulty with eructation, taking several minutes to elicit, trouble eliminating stool accompanied by crying; immediate crying when lying supine | SMT performed with diversified technique modified for gestational age and size using low force; 1x/week, 4 weeks, re-evaluation with tx after 4 weeks | Cannot say | Cannot say | No AE due to chiropractic manipulation was reported by the parent |
Dorough, 2018 [58] | 2.5-year-old; male; speech delay, difficulty lying prone, unable to lift head up well, crying when pushing up from ground | Cervical spine modified Gonstead Technique and instrument-assisted Sigma-Instrument; 7 visits 1x/wk., 8 weeks | Cannot say | Over the course of treatment | No adverse reactions to tx were reported to occur with the intervention |
Martin-Marcotte, 2018 [59] | 21-month-old; female; episodes of constipation for the past 15 mos | Modified Diversified Technique for the child’s age and development; 2x/week, 4 weeks, re-evaluation after 10 visits, 1x/month subsequently | Cannot say | Over the course of treatment | No adverse reaction to adjustment reported |
McCormick, 2018 [60] | 15-month-old; male; motor developmental delay, not able to crawl, pull up to stand, stand alone or walk | Full spine SMT with Diversified Technique (Activator instrument-assisted); 1x/week for 4 weeks, 1x/every other week for 12 weeks | Cannot say | During the course of care | No adverse reactions were identified or reported to occur with the intervention |
Lacroix, 2016 [64] | 4-month-old; female; recurrent regurgitation after feeding, averse to being carried, difficult eructation, interrupted sleep, choking and rumination, wheezing during sleep, fussiness, distended stomach, excessive intestinal gas | 17 chiropractic adjustments over 20 weeks; craniosacral technique and Diversified adjusting technique (high velocity low amplitude) | Cannot say | During the course of care | No AE were reported to occur with the intervention |
Makela, 2018 [65] | 3-year-old; female; autism spectrum disorder, no verbal or non-verbal communication, off balance when walking, toe-walking 50% of the time | SMT provided on 11 visits over 6 weeks; spring-loaded instrument assisted technique; after re-evaluation, 2x/week with re-evaluation every month (Dec – Mar) | Cannot say | During the course of care | No adverse reactions to treatment were reported |
Dobson, 1996 [46] | 5-year-old; male; asthmatic; seeks care to promote “normal” & vitality posture; ROM limited in extension; muscle tension cervical spine; neutral lateral radiograph revealed an os odontoideum | 3x/week for 4 weeks, 4x/week for 2 weeks, 1x/week for 3 years; toggle-recoil (short lever high velocity, very low amplitude) adjustment when indicated | Cannot say | Cannot say | No negative effects were experienced with the intervention |
Wilson, 2012 [48] | 21-day-old; female; reported to pediatrician w/ concern of abnormality/ crepitus on back; presented to chiropractor due to fussiness and colic at 16-days-old | Day 23, follow-up investigation by child abuse center with the chiropractor confirmed the parents report. Parents described chiropractor initially held patient upside down by hips, with hands around hips and lower ribs. Applied pressure along spine with fingertips. Used a “spring-activated device” on back (in same location of fracture), while patient lay prone on the mother’s chest. | Chest radiograph and investigation by child abuse center to confirm reports | At 35 days of life, evidence of rib fracture healing with no new fractures | Acute fractures of 7th and 8th posterior ribs |
Shafrir, 1992 [51] | 4-month-old; male; head tilt noted in first week of life attributed to neck trauma during delivery, noted discomfort when placed on abdomen, could not raise head from prone; told would resolve but no improvement in head tilt after 4 months | First tx: Neck manipulation including flexion, extension and axial loading and unloading Second tx: parents returned after first response to manipulation, were reassured and infant was provided another neck manipulation | 3 h post second tx, admitted to hospital; routine chest radiograph showed enlargement of the spinal canal from C3-T8. MRI of the head and spine showed a mass within the spinal cord, extending into the medulla superiorly and occupying the entire canal from mid-cervical to the lower thoracic region. During surgery, thrombosed veins were noted on the dorsum of the enlarged spinal cord, when spinal cord was incised at C6 level, creamy white, viscoelastic tumour tissue exuded spontaneously. No normal cord tissue was identifiable at this level. Cervical and lower thoracic portions of the tumour were easily removed from normal-appearing spinal cord tissue. Pathologic examination revealed mostly necrotic tissue, with the lack of inflammatory infiltrates (suggesting acute necrosis, rather than due to a high-grade malignancy), with several areas of low-grade astrocytoma. | Immediately after tx | After first tx: difficult to arouse him from a nap, he was described as limp, pale and moaning After second tx: immediately post-manipulation was alert, later began to moan and grunt continuously, fed poorly, fever developed. Three hours after second neck manipulation, he was admitted to the hospital, where he was described as listless and fussy, w/ a weak cry. Early next morning, he had a brief, generalized seizure, followed by “gasping” respirations and cyanosis, requiring tracheal intubation, followed by another 3 h seizure. Infant was admitted to the intensive care unit while comatose and rarely responsive to painful stimuli. Later, infant opened eyes and had conjugate movements. Infant had flaccid paralysis of both legs and right arm, with some active motion and withdrawal of the left arm. Post-operatively, infant regained motor and sensory function to the T4 level. 18 months later, he had full use of the upper extremities, sensory function at approximately T9 level and some spontaneous but non-functional motion of the right leg. Diagnosis: congenital spinal cord astrocytoma |
Humphris, 2014 [52] | 6-month-old; female; left head rotation and ipsilateral flattening of her posterolateral cranium, frequent regurgitation of breast milk immediately after feeding with inability to feed from the right breast, unsettled sleep patterns | 3 visits over 4 months; Diversified technique with a light, modified, HVLA impulse; no other interventions provided | Cannot say | Cannot say | No AE were reported or observed to occur with the intervention |
Fairest, 2013 [54] | 6-week-old; female; left-sided cranial flattening and favored left head rotation, occasional regurgitation of an entire breastfeed immediately after feeding, groaning when placed prone in an inclined position, unsettled sleep patterns; advised by GP & midwife to seek chiropractic care | 1x/week, 10 weeks; 7 visits included Diversified technique (modified HVLA thrust) to cervical (7 visits) and sacrum (1 visit) and Activator to thoracic (2 visits), 3 visits of no SMT | Cannot say | Cannot say | No AE were observed, nor reported to occur with the intervention |
Gordon, 2011 [55] | 2-week-old; male; facial and upper limb postural asymmetry following a forceps-assisted vaginal birth after Caesarean, droopy lip on the right, right arm assumed waiter’s tip posture at rest | Chiropractic craniosacral techniques: low-force static hold adjustments to cervical and sacral segments; soft tissue therapy to cervical muscles; 2x/week for 2 weeks, then 1x/every other week for 12 weeks | Cannot say | Cannot say | No adverse effects of management were reported |
Statistical analyses
Evidence synthesis
Reporting of outcomes
Results
Study selection
Risk of Bias within studies
Author, Year | 1.1 | 1.2 | 1.3 | 1.4 | 1.5 | 1.6 | 1.7 | 1.8 | 1.9 | 1.10 | Overall assessment |
---|---|---|---|---|---|---|---|---|---|---|---|
Miller, 2012 [61] | Y | Y | Y | Y | Y | Y | CS | Tx blinded: 0 Tx not-blinded: 0 No tx: 12 | Y | N/A | + |
Sawyer, 1999 [32] | Y | Y | Y | Y | N | Y | CS | SMT: 0% (0/9) Placebo: 9% (1/11) | Y | N/A | + |
Risk of Bias table: Low risk of bias - Cohort Studies | |||||||||||||||
Author, Year | 1.1 | 1.2 | 1.3 | 1.4 | 1.5 | 1.6 | 1.7 | 1.8 | 1.9 | 1.10 | 1.11 | 1.12 | 1.13 | 1.14 | Overall Assessment |
Saedt, 2018 [33] | Y | N/A | Y | N/A | CS | N/A | Y | N/A | CS | CS | N | N/A | N/A | N | + |
Risk of Bias table: High risk of bias - Cohort Studies | |||||||||||||||
Author, Year | 1.1 | 1.2 | 1.3 | 1.4 | 1.5 | 1.6 | 1.7 | 1.8 | 1.9 | 1.10 | 1.11 | 1.12 | 1.13 | 1.14 | Overall Assessment |
Douglas, 2016 [74] | Y | N/A | N | N/A | 0% | N/A | CS | N/A | N | CS | N | N/A | N/A | Y | – |
Risk of Bias table: Low risk of bias - Case Report & Case Series | |||||||||
Author, Year | 1.1 | 1.2 | 1.3 | 1.4 | 1.5 | 1.6 | 1.7 | 1.8 | Overall assessment |
Hubbard, 2010 [62] | CS | Y | CS | N | N/A | CS | Y | Y | + |
Muir, 2012 [63] | CS | Y | CS | Y | N/A | CS | Y | Y | + |
Bourque, 2018 [53] | CS | Y | CS | N | N/A | CS | CS | Y | + |
Iyer, 2017 [34] | CS | Y | CS | Y | N/A | CS | CS | Y | + |
Young, 2017 [56] | CS | Y | CS | CS | N/A | CS | CS | Y | + |
Berube, 2004 [57] | CS | Y | CS | Y | N/A | CS | CS | Y | + |
Dorough, 2018 [58] | CS | Y | CS | N | N/A | CS | CS | Y | + |
Zhang, 2004 [35] | Y | Y | CS | CS | N/A | CS | CS | N | + |
Martin-Marcotte, 2018 [59] | CS | Y | CS | CS | N/A | CS | CS | Y | + |
McCormick, 2018 [60] | CS | Y | CS | CS | N/A | CS | CS | Y | + |
Lacroix, 2016 [64] | CS | Y | CS | CS | N/A | CS | CS | Y | + |
Makela, 2018 [65] | CS | Y | CS | CS | N/A | CS | Y | Y | + |
Paravicini, 2018 [66] | Y | Y | CS | CS | N/A | CS | Y | Y | + |
Dobson, 1996 [46] | CS | Y | CS | CS | N/A | CS | CS | Y | + |
Alcantara, 2008 [47] | CS | Y | CS | CS | N/A | CS | Y | Y | + |
Wilson, 2012 [48] | CS | Y | Y | Y | N/A | CS | Y | Y | + |
Alcantara, 2010 [49] | Y | Y | CS | CS | N/A | CS | CS | Y | + |
Miller, 2008 [50] | Y | Y | Y | Y | N/A | CS | Y | Y | + |
Shafrir, 1992 [51] | CS | Y | Y | Y | N/A | CS | Y | Y | + |
Humphris, 2014 [52] | CS | Y | CS | Y | N/A | CS | CS | Y | + |
Fairest, 2013 [54] | CS | Y | CS | Y | N/A | CS | CS | Y | + |
Gordon, 2011 [55] | CS | Y | CS | CS | N/A | CS | CS | Y | + |
Risk of Bias table: High risk of bias - Case Report & Case Series | |||||||||
Author, Year | 1.1 | 1.2 | 1.3 | 1.4 | 1.5 | 1.6 | 1.7 | 1.8 | Overall assessment |
Kinkpe, 2009 [39] | CS | CS | Y | N | N/A | CS | Y | N | – |
Nicolas-Schmid, 2016 [40] | Y | N | Y | CS | N/A | CS | N | N | – |
Cox, 2016 [41] | Y | N | CS | CS | N/A | CS | CS | Y | – |
Miller, 2009 [42] | Y | CS | CS | CS | N/A | CS | CS | Y | – |
Ghanim, 2019 [43] | CS | N | Y | Y | N/A | CS | Y | Y | – |
Deputy, 2014 [44] | CS | CS | Y | N | N/A | CS | Y | Y | – |
Wiberg, 2010 [45] | Y | CS | CS | CS | N/A | CS | CS | N | – |