Pediatric Standards of Care

Recently, a hot topic in chiropractic has been standards of care for patient treatment. With publication of the findings of the RAND study and the proceedings of the Mercy Center Conference, specific criteria, or base line measurements have been identified from which patient management programs for specific conditions can be developed. In this article, we will examine the need for such criteria in the chiropractic treatment of children.

Frequently, I am called upon by chiropractors to comment on evaluative judgments which have been made by insurance office claims inspectors relative to chiropractic treatment that has been provided for children. Frequently, it appears that insurance companies seek to deny claims for the chiropractic care of children, simply on the basis that they do not consider that children need chiropractic care. These assertions are likely being made on the lack of scientific publications in the literature dealing with the results of chiropractic intervention in pediatric disorders.

The correction of these unfavorable third-party evaluations requires education of the claims inspectors with well-documented case reports, as well as the establishment of a solid database of evidence supporting the results of chiropractic care for children. This task is under way, but it still needs more support from the treating doctors in the profession in the form of published reports of interesting cases, and from researchers and academics in the form of detailed studies of the efficacy of pediatric chiropractic care.

One wonders if only we could have the parents of the many children who have regular chiropractic check-ups speak to these claims inspectors, we might have an entirely different response. Parents of children who have undergone several years of drug therapy without response, who finally have their problem corrected following a few trips to the chiropractor, make a strong case for the need for spinal evaluation as a regular part of childrens' health care programs.

A survey of the chiropractic literature of the past few years will identify small series studies and case reports of successful chiropractic treatments for varied conditions such as asthma, bronchitis, colic, enuresis, growing pains, hyperactivity, tonsillitis, and torticollis.

I suggest that chiropractors who have difficulty convincing parents or third-party payers that chiropractic for kids is not only appropriate but, in many cases, necessary for health, should refer to some of these articles.

The wider issue of appropriate standards of care for pediatric patients needs to be considered from several viewpoints:

Firstly, treatment protocols for children with identifiable and diagnosable disorders and, secondly, chiropractic programs for well children. Obviously, the intensity of a treatment program for a sick child will vary according to the condition which is being treated. Programs for healthy children will normally require less frequent adjustments and will usually vary according to the age of the child being treated. For example, a child who presents for a spinal examination, without any chief complaints, may receive significantly less treatment than a child who has a chronic upper respiratory condition.

For well child care, it is recommended that the standard minimum protocol be classified according to various age groups. The following guidelines may be useful until more detailed studies are available.

Birth to 12 months.

Six spinal examinations each year, scheduled as follows:

1. During the first two weeks after birth
2. When the child can support and lift the head
3. When the child begins to sit
4. When the child begins to crawl
5. When the child begins to stand
6. When the child is walking

- Three spinal examinations each year

Six years to 12 years

- Four spinal examinations each year

13 years to 18 years

- Six spinal examinations each year

The above classifications are based broadly on the relative incidence of traumatic events which may precipitate spinal subluxations. Other incidents may, however, require that these treatment programs be modified to provide more frequent chiropractic care.

Examples of spinal conditions which may require changes to the above treatment programs include postural or spinal deformities, such as congenital and idiopathic scoliosis, pelvic and shoulder unleveling, head tilt or rotation. Each of these examples may require an increased frequency of office visits for evaluation, treatment, and subsequent monitoring.

Common childhood disorders, such as otitis media, tonsillitis, asthma, enuresis, colic, and growing pains, all may require a variation to the above protocol. A program of one office visit each week, for four to six weeks, could be considered quite usual with a follow-up program of one to two treatments per month being required in some chronic cases.

These guidelines are presently used by many of the DCs who have attended my pediatric seminars. They are presented simply as a guide from which to establish the specific protocols required to manage the wide range of pediatric patient problems which present to chiropractic clinics throughout the world.

Peter Fysh, D.C., B.APP. Sc.
Sunnyvale, California