Evaluating Prenatal and Pediatric Automobile Injuries

Often in a family practice, one of your patients or an entire family is in an automobile accident and you are sought out to provide care for their soft-tissue injuries. Depending on the severity of the collision and individual complaints, each of the occupants may need to be treated differently.

This is a brief introduction and overview of chiropractic care for the prenatal and pediatric patient following a collision injury. Be aware that these patients may require care by other specialists, but I the following is not a narrative or advice on co-management of the injured individual.

The Prenatal Patient

Prior to your consultation, request that all accident reports and examinations by other providers be forwarded in advance for your review. The first point for consideration is the prenatal patient's stage of pregnancy and the immediate care offered as a result. For instance, if the occupant is in her first trimester, it was probably recommended that she go to her OB for an evaluation; whereas if she is in her second or third trimester and/or the driver of the vehicle, especially if she were close to the steering wheel at the time of the crash, the airbag deployed and/or if she felt abdominal trauma from the seatbelt, she may have first gone to the emergency room and followed up with her OB once released.

There are several questions you might consider asking the pregnant patient about what happened during the collision (after asking these, pose the traditional personal-injury questions):

• How was the seatbelt used?
• What position was your body in at the time of the collision?
• What position was your body in when the car came to rest?
• Did the airbag engage and where was the point of strongest contact?
• Did you experience bruising from the airbag or seatbelt?
• What was reported by your OB?

Note that increased levels of the hormone relaxin may have caused increased ligament laxity in the prenatal patient, which may cause a more symptomatic picture. For example, if the patient's arms were on the steering wheel, she may have an increase of cervical and thoracic instability. If her right leg were extended out on the pedal (gas or brake), her pelvis may have been in rotation upon impact.

A comprehensive chiropractic, orthopedic and neurological examination to document the nature of the injury and provide more recommendations for an appropriate treatment plan is required. The examination must include enough procedures that would allow you to write a comprehensive report for an OB or attorney if they are co-managing the case.

Regarding radiographing the cervical spine of the pregnant patient, the doctor must determine if taking this series (within their practice or referring out to an X-ray facility) is warranted due to the clinical findings of the examination. All precautions (lead shielding) are mandatory and the doctor must always weigh the benefits versus risks of radiographing with shielding, and discuss this with the patient and possibly other health care providers involved with her care.

The Pediatric Patient

In the United States in 2011, more than 650 children under the age of 12 died and 148,000 were injured in motor-vehicle accidents,¹ while in 2012, more than 2,000 teenagers (ages 13-19) were killed.² As described by Murphy³ in his chapter in Pediatric Chiropractic, 2nd Edition, there are many contributing factors to the injury of a pediatric patient involved in a collision. Anthropometric and positioning variables include head size, pelvic height, anterior-superior iliac crest and the center of gravity, to name a few.

The pediatric population may be one of the most underserved when it comes to post-automobile-collision treatment. Many children are deemed "normal" because they "were in a car seat" or "have no apparent symptoms" (e.g., no headaches or neck pain), so parents and those in the medical field may inadvertently not be aware that the child could have soft-tissue injuries warranting a musculoskeletal exam.

In my clinical experience with infants and young children, I have often seen what I call the "silent signals"– subtle but notable abnormal functions reported by the parents. Some of these signals include positional discomfort (putting the infant or a toddler in a certain positions causes discomfort), night terrors, picky eating, bowel disruption (usually constipation), and being clingy, anxious and/or unable to focus in the classroom. If a parent is not sure if their child has been injured, one can always rule it in or out by performing an exam.

Consultation questions to include with your traditional questions (ask the parents of the pediatric child or the child, if old enough to communicate clearly) include the following:

• What type of restraint system was used in the vehicle?
• What position was the child in before and after the injury?
• Was there crying, confusion, signs of pain or discomfort after the accident?
• What other symptoms besides neck, back pain or headaches is the child experiencing?

Your exam of the infant to age 5 child should include static and motion palpation, ROM, and orthopedic and neurological examination. Take X-rays (or refer out for radiological exam) if X-rays are warranted. For patients ages 5 and older, I suggest the above, but I would include selective X-ray views.

Re-examinations of the pediatric patient are recommended every 30 days or 12 visits. Parents should be asked during the examination and each treatment visit, about their child's overall quality of life since the accident, including sleep, digestion, elimination, behavior, etc. Also inquire as to any activities the child has been unable to do – or been limited in doing – post-accident.

The Child Advocate: If Not You, Then Who?

It should be noted that the insurance community is not embracing the legitimacy of soft-tissue injuries in the pediatric population. I have found that it requires extensive documentation, having the parents involved with their pediatrician, sending out periodic update reports to the child's other doctor(s), and sometimes the involvement of an attorney (one willing to accept a case even if it appears to be minor and who believes in advocating for the right of the child to receive necessary and appropriate care). In some cases, I have even provided the insurer with a copy of Pediatric Chiropractic so they can review Dr. Murphy's chapter.

Sadly, some of our colleagues have earned us a bad rap (and thus the challenges from the insurance industry) when it comes to the care of individuals with car injuries, but that small percentage should not cause the majority of us to think twice about caring for the pregnant or pediatric population. It would be unethical to selectively eliminate certain population groups (pediatric, special need, etc.) access to appropriate care via chiropractic.

I encourage our profession to advocate for the child patient and the mother of the unborn child in the event of an automobile collision. Perform the necessary examinations and document your findings to provide appropriate care for this important patient group.

References

1. Child Passenger Safety: Fact Sheet. Centers for Disease Control and Prevention.
2. Teen Driver Car Accident Statistics - 2012. Law firm of Edgar Snyder and Associates.
3. Murphy D. Children in Motor Vehicle Collisions. In Pediatric Chiropractic, 2nd Edition. Philadelphia, PA: Lippincott Williams & Wilkins, 2012.

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The pediatric examination may vary due to the nature of the injury, but the following chapters of Pediatric Chiropractic, 2nd Edition, may prove useful in helping guide a comprehensive exam: Chapter 6 – the prenatal patient and neurological examinations for the neonate; chapters 9, 11-12 – neurological examinations; chapter 13 – orthopedics; chapter 4 – diagnostic Imaging; and chapters 5, 28-34 – techniques for spinal and cranial examination.