On the December 14th episode of the Emmy Award winning “talk show-informative” spin off of a spin off (Oprah begat Dr. Phil, who in turn begat) The Doctors, the segment “Is It Safe for Babies to Go to the Chiropractor?” was aired. The Doctors, which debuted in 2008, is a program that aims to provide accurate and trustworthy information on a variety of medical topics but fails to do so roughly half of the time. It tends to be more accurate than friend of SBM, Dr. Oz, but still generally adds to our societal burden of medical misinformation. In this particular segment, a skeptical viewpoint is present but it is overpowered by false balance and and an amateur, though clearly well-meaning, attempt to counter common claims of so-called pediatric chiropractors.
A little shock and awe
As the segment opens, host Dr. Travis Stork, who I knew while in residency at Vanderbilt and have always thought was a nice and well-meaning puppet on the string of ignorant writers and producers, introduces the concept of newborn chiropractic with a brief video of a chiropractor adjusting a 12-day-old infant. To his credit, he comes across as skeptical and the clip is met with what appears to be shocked silence interrupted by a few gasps and one loud exclamation of “What?” This is exactly how I responded when I first learned that this was something that many chiropractors recommend.
Stork then points out that newborn visits to chiropractors are becoming more common but I’m not sure how he knows this. There is no data to my knowledge that specifically addresses this question. I imagine that he is basing this assessment on the biased information producers obtained from the chiropractors involved in the segment. What I do know is that claims of treating newborns, often in numbers that are hard to believe (just wait), are very common on individual practice websites and that there are many fumbling news articles (check out the token skeptic in this one!) and online parenting resources that discuss the subject haphazardly in such a way as to legitimize the practice and make is seem more prevalent than it likely is.
It is easy to come to the conclusion that increasing numbers of parents are bringing their newborns to see chiropractors based on what can be found online. Sadly I wouldn’t be surprised if the numbers are increasing a bit, but I am skeptical that it is significant considering that data from NHIS reports over the past 14 years hasn’t revealed an increase in overall pediatric visits. Another reason to be skeptical is that claims of treating impressively large numbers of patients is a common tactic taught in chiropractic practice-building programs. It is also easy to find individual chiropractors and even major chiropractic organizations like the International Chiropractic Pediatric Association claiming to treat “shaken-baby syndrome” or to prevent sudden infant death syndrome, all in an effort to drum up business.
Chiropractors are desperate for business. Despite the claims of chiropractic colleges and practice-building firms, they have high rates of failure and difficulty repaying student loans. Competition is fierce and America’s strip malls are practically littered with former chiropractic offices. Recruiting younger patients and focusing on wellness care and prevention (“You don’t wait until you have a cavity to see the dentist, do you?”) are a huge aspect of practice-building firm recommendations on how to ensure a steady and reliable cash flow.
A skeptic emerges from the audience
Dr. Stork follows up the video of a baby (and his or her caregivers) being manipulated by a chiropractor by introducing a representative of “the world of pediatrics,” pediatrician Dr. Dafna Ahdoot. As is common on the show, Adhoot was placed in the audience rather than on stage. It’s awkward, it undermines her authority, and I’ve never understood why they do this.
She is given the opportunity to speak first, to anticipate the claims certain to be made by the chiropractic proponents waiting to speak and pull the rug out from under them. Unfortunately she undermines her own authority on the subject by revealing that she doesn’t actually know anything about the subject and refers to it as “pediatric chiropracty.” While not unheard of, use of “chiropracty” as a noun is odd. It may have just been nerves though.
Adhoot then mentions how the video is disturbing to her as a mother, which I also find a bit unfortunate. As a father, I’m also disturbed by this practice but I don’t see how it is relevant. Setting the stage with an emotional statement like that further weakens her position of authority on pediatric care in my opinion.
She then appeals to her pediatric expertise and understanding of why some parents may turn to alternative therapies when their children are ill. Many caregivers do feel helpless when their loved one isn’t recovering from an illness or injury, and medical doctors sometimes have no available curative treatment at their disposal. Sometimes the phony validations and false promises found in the offices of irregular medical practitioners can lead a parent or caregiver to believe that they are doing the right thing. But Adhoot misses an opportunity to point out that most newborns seen by chiropractors are perfectly healthy and are being adjusted to treat common, benign, and self-limited complaints such as general fussiness, colic, breastfeeding difficulty, and reflux. She could have told the audience that any treatment would appear to be effective in these circumstances.
Adhoot then attacks what is largely a strawman argument when it comes to newborn chiropractic, although there are exceptions. She describes how “forceful sudden movements” applied to the body of a young infant puts them at risk of muscle spasms, fractures, and neurological damage. While certainly possible, infant chiropractic rarely involves the high-velocity, low-amplitude adjustments often associated with chiropractic care.
The overwhelming majority of chiropractors who treat babies employ very gentle adjustment techniques, often using handheld spring loaded devices called Activators that impart barely enough force to briefly indent the skin let alone break a skull or spinal bone. Chiropractors who see kids frequently work the gentle nature of the treatments into their sales pitch, usually comparing the amount of force used to checking a tomato for ripeness. One of Stork’s co-hosts, a plastic surgeon, even points out that it looked like all the chiropractor was doing was infant massage. Unfortunately this ends up making Adhoot potentially come across as alarmist and allows the defenders of chiropractic to reassure the audience.
This could have been an opportunity for Adhoot to point out that while direct harm is extremely rare, although not unheard of, this isn’t why bringing a baby to the chiropractor is problematic. Chiropractic training is woefully inadequate when it comes to pediatric care. They are simply not trained to recognize serious pathology, which can be subtle in young infants. To give just one of countless examples, an infant with a life-threatening intestinal obstruction called intussusception may presents as simply more fussy or sleepy than usual. As a chiropractor searches for non-existent subluxations, a child’s bowel may be dying. To be fair, Adhoot later implies this concern but it is a weak argument thrown in too late.
In addition to this form of indirect harm, chiropractic involvement in pediatric care tends to undermine the recommendations from science-based medical providers. Anti-vaccine sentiment, for example, is rampant in the chiropractic community. And although even indirect harm such as this remains uncommon, thanks to a still decent herd immunity in most regions and the fact that most parents are unlikely to, when push comes to shove, bring an obviously young infant to the chiropractor instead of the pediatrician, family doctor, or emergency department, any risk whatsoever is far too high when compared with the utter lack of proven benefit from chiropractic in this patient population.
Two defenders of baby chiropractic join us on Skype
Dr. Stork then introduces a husband and wife chiropractic team, Stuart and Theresa Warner, who in addition to running a practice that reportedly consists of 75% children and pregnant women, also run a practice-building company that teaches other chiropractors how to convince parents of the importance of pediatric chiropractic in order to bring in more patients. Their tactics, in addition to a bit of insurance fraud, has gotten them into trouble in the past. So rather than two ambassadors for pediatric chiropractic care looking to educate the audience, The Doctors has provided a forum for a couple of shady salesmen to advertise themselves as a product.
Stork opens by revealing that he loves chiropractic and is, in fact, heading to one as soon as the show is done taping. Despite this, he admits concern regarding infant care. The Warners respond by claiming that “chiropractors have been adjusting kids for over a hundred years and that tens of millions of adjustments are safely and effectively given to children each and every year.”
Chiropractic was invented in 1895 by Daniel David Palmer, not exactly out of whole cloth but essentially as a clone of osteopathy that focused primarily on the spine. I have no doubt that some practitioners began treating children in the early days. Some also claim to be able to adjust the spines of elephants and horses with their bare hands, an accomplishment that has near homeopathy level implausibility. But those numbers I find hard to believe and consider it to be typical marketing hyperbole. Every chiropractor in America would need to perform hundreds of pediatric adjustments per year.
Stuart Warner then repeats a common canard that goes unchallenged. He asks the audience to consider that “chiropractic malpractice rates are a fraction of what other doctors pay because what we do is safe.” This may be accurate, but it says nothing about whether or not what they do is effective. Also they don’t take care of ill patients. He says this to counter Adhoot’s exaggerated warnings about potential harms and no doubt scores a few points with uninitiated viewers.
He follows this with another easily countered and extremely common claim, that the delivery process puts a newborn’s neck through extreme degrees of torsion and traction and is much more harsh than chiropractic adjustments. This implies that babies develop spine problems that must be diagnosed and treated by chiropractors. Adhoot could have headed this off at the pass by pointing out that while some babies do suffer birth trauma, there is no evidence that injury to the spine is common or, in rare cases where it occurs, subtle enough to be missed by medical practitioners in the newborn nursery. She could have told the audience that millions of babies are born every year who develop normally and have no major medical problems without ever setting foot in a chiropractic office.
Warner claims that “parents today are understanding and recognizing the important role that the spine and nervous system plays in their child’s health and well-being. Statements like this are pure marketing boilerplate used on hundreds if not thousands of individual practice websites. Of course the spine and nervous system are vital to our health at any age, but this begs the question that chiropractors can do anything to recognize and treat problems with them.
Outside of some evidence of benefit, primarily when doing things also done by physical therapists, for a very small number of musculoskeletal complaints in adults, there is no reason to believe that chiropractors play any role in any patient’s health, especially a pediatric patient. This claim is also commonly used to imply that chiropractic subluxations can result in general health concerns, weakened immune systems, and impaired development. They do not because they don’t exist. They would not even if they did.
Where is the evidence?
One of the co-hosts of the show, a gynecologist who also earlier questioned the chiropractors’ claims regarding birth trauma, asked about actual evidence of safety and benefit for infants. Theresa Warner, who looks an awful lot like Bridget Fonda, responds by claiming that “there are more and more studies being done all the time and that data shows the efficacy of chiropractic care for children.” This is true but extremely misleading. Yes, more publications on chiropractic care of children appear at a steady rate, but they are of the poorest methodological quality, almost exclusively found in journals with clear editing bias, and mostly consist of unblinded case reports and pragmatic studies practically designed to give positive results.
The master marketers know that scientific evidence isn’t really what prospective patients and patient parents tend to respond to however. So it came as no surprise to me whatsoever when Theresa Warner followed her praise of the chiropractic literature by stating that “the truth is in the patients. There are millions and millions of moms and dads who will testify as to the life changing benefits that chiropractic has had for their family and their children. In 24 years of practice, we’ve seen nothing but children really benefitting.” Again, these numbers are highly suspect. Also sketchy are claims of 100% success in any form of healthcare. That just isn’t how the body, or the real world, works. This claim, which is just another marketing sound bite carefully constructed by this dynamic duo of pseudomedical nonsense, only reveals the degree to which confirmation bias can warp our perception of reality.
More fear mongering…from the pediatrician!
Sadly, Dr. Adhoot only appears to have prepared one line of argument to counter the claims made by infant chiropractors. When asked again about potential risks associated with the practice, she mentions atlanto-axial instability and spina bifida. The former, an extremely rare condition except in children with Down syndrome, would put a patient at risk of spinal cord injury should they undergo neck manipulation. The latter, a much more common condition, primarily involves the lower spine and is clinically silent in most patients. It would be very unlikely for a child with the most common form of spina bifida, which goes undiagnosed in the vast majority of patients, to be harmed by chiropractic adjustment. And infants with the uncommon but considerably more clinically obvious form would be extremely unlikely to be seen by a chiropractor.
Her worries have merit, but as I previously discussed they aren’t the main reason why infant chiropractic is of concern. And once again they are easily countered because she focuses on the rarely used high-velocity, low-amplitude adjustment techniques. Theresa Warner responds by stating that these conditions would be picked up during their initial history taking and exam, which is not true, but also that these patients would have already been evaluated by medical professionals and diagnosed prior to coming in for chiropractic care. This is also sadly not always true. Specifically in the case of atlanto-axial instability in a child with Down syndrome, 15% of patients would be at risk of severe injury and even death if their necks were jerked around and most go undiagnosed.
Final thoughts from Dr. Stork and friends
It’s clear that the co-hosts of The Doctors, who aren’t shy about endorsing medicals nonsense, are skeptical of chiropractic for young infants. Stork, a believer in chiropractic care for himself, straight up says he doesn’t buy what they are selling. They close the segment by pointing out the importance of having newborns evaluated by a pediatric professional. They also point out the need for good communication between families and their child’s doctor. So great job team. Wait….
Despite the obvious skeptical stance taken by the hosts of The Doctors, the segment was a train wreck. The pediatrician invited to serve as a medical authority, though clearly well-intentioned, was inadequately prepared and none of the bogus claims made by the two chiropractors were effectively challenged. The Doctors followed the same format so often used in the media, offering equal time to two opposing viewpoints. Sometimes that is acceptable, but not in situations such as this where the weight of the evidence is so clearly on one side.
There is no real debate over the safety and efficacy of newborn chiropractic. Their claims, some of which may have a thin patina of legitimacy, are easily revealed to be total nonsense with minimal skeptical investigation. Sadly, the segment gave an undeserved opportunity for two chiropractors to promote themselves and their practice. it is likely that many viewers will come away from the segment confused about the subject or even more accepting of bringing newborn infants to a chiropractor.
Newborn Chiropractic, False Balance, and The Doctors Clay Jones