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Chiropractic management of infantile colic
Clinical Chiropractic (2004) 7, 180—186
CASE SERIES
Chiropractic management of infantile colic Andrea J. Hipperson Wight Chiropractic Clinic Ltd, 30 Roseburn Place, Edinburgh, EH12 5NX, Scotland, UK Received 1 August 2003; accepted 18 February 2004
KEYWORDS Chiropractic manipulation; Infantile colic; Paediatric human; Somatovisceral reflexes
Abstract Objective: To present two case studies in which the complete resolution of infantile colic and associated symptoms was achieved with chiropractic treatment. This case series supports the aetiological mechanism of an imbalanced autonomic nervous system, via somatovisceral reflexes secondary to regional cranial and spinal dysfunction. In addition, they provide support towards the birth process being a causative factor in the development of colic. Design: A case series. Setting: Private chiropractic practice. Subjects: The first case involved a 7-week-old male infant presenting with medically diagnosed colic, with associated reflux and disturbed sleep, all of which were persistent since birth. The second infant, aged 10 weeks, had suffered maternally diagnosed colic for approximately 1 month. Associated symptoms included some vomiting and asymmetry with breast-feeding. Both infants demonstrated many typical colic characteristics and had experienced birth trauma. Upper cervical, mid thoracic, sacroiliac and cranial dysfunction was recorded in both cases. Methods: Each infant received diversified paediatric chiropractic manipulation to the areas diagnosed as dysfunctional. Treatment was provided over a 3-week period, though the intensity differed for the two infants. Results: Complete resolution of all presenting symptoms was achieved in both instances. Conclusion: These cases suggest a possible association between birth trauma; the development of cranial and spinal segmental dysfunction and consequential manifestation of symptoms of infantile colic. Secondly, they demonstrate chiropractic treatment successfully restoring correct spinal and cranial motion, with an associated resolution of symptoms. ß 2004 The College of Chiropractors. Published by Elsevier Ltd. All rights reserved.
Introduction Paediatric patients commonly present to chiropractic practice with gastrointestinal symptoms. When considering bowel function, constipation and diarrhoea are located at opposite ends of a continuum, infants often fluctuating between the two. Colic, however, is seen as a separate entity, a paediatric condition of unknown aetiology,1—13 classically developing within the first 4 weeks of E-mail address: [email protected] (A.J. Hipperson).
life3,6,10,14,21 and spontaneously resolving by 3—4 months of age.3,5,10,16,18—23 This paper proposes that paediatric constipation, diarrhoea and colic can have a shared aetiology and are actually variations of the same condition: a gastrointestinal motility dysfunction due to an autonomic nervous system (ANS) imbalance. Two definitions of colic are most widely utilised. The first is the ‘‘rule of 3’’ in which the characteristic colicky cry lasts for more than 3 h per day, more than 3 days per week for a minimum of 3 weeks.24 The second is Illingworth’s15 ‘‘3 months colic’’. This
1479-2354/$30.00 ß 2004 The College of Chiropractors. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.clch.2004.02.003
Chiropractic management of infantile colic
describes evening episodes of idiopathic, rhythmic crying, with associated facial redness, clenched fists, knees tightly drawn to the chest, flatulence and loud borborygmi up to 3 months of age. It must be appreciated that there is no standard diagnostic criteria for colic and thus studies adopt varying criteria rendering them incomparable in many instances.3,7,25,26 Theoretical discussions, proposed incidence, mechanisms of causation and management efficacy therefore almost certainly involve a heterogeneous group of infants with varying problems. Many aetiological factors for infantile colic have been explored amongst the literature including breast versus bottle-feeding, cows’ milk intolerance, parental anxiety, maternal demographic data, socioeconomic factors,2,7,10,16,17,22,23,26—28 parity, birth weight and other obstetric factors,1,3,4,13,15,29—31 but results have been conflicting and inconclusive. The chiropractic approach views colic symptoms as a consequence of the vertebral subluxation complex and cranial dysfunction, which can be sub-clinical entities resulting from peri-natal trauma or physical stress,33,34,37,73,76 the risk of which are greatly increased by several factors. These include in utero constraint; rapid or prolonged labour; foetal malpresentation such as occiput posterior, breech, face, brow or transverse delivery; assisted delivery using forceps, ventouse or manual traction and caesarean section.10,32,34,37,42,45,76,79 ‘‘Normal birth’’, which is generally considered absence of the previous obstetric factors, is not necessarily problem-free32—35 as distortional, compressive uterine forces will still be applied to the foetus regardless how ‘easy’ and uncomplicated the process.32,34,37 This alone can be responsible for foetal injury.38 Anecdotal reports show chiropractic spinal manipulation therapy to be successful in the treatment of infantile colic,6—8,10,12,20,42—45 as do limited clinical research trials.46 A 1989 study found that 94% of 316 cases of colic improved with chiropractic treatment.3 Placebo was not considered due to absence of a control group, but Wiberg et al.,31 excluded this limitation. Their randomised, controlled trial with a blinded observer showed chiropractic manipulation to be significantly more effective in the treatment of colic than the medical approach of Dimethicone (P ¼ 0:04, n ¼ 42) after only 4—7 treatments. The small sample number was still a limitation however and the parents were not blinded, thus a possible bias persists47 demonstrating the need for further research of this nature. These case reports demonstrate two infants relieved of colic by chiropractic treatment and discusses their birth processes as an aetiological factor and whether chiropractic may act to correct any resultant imbalance in the ANS.
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Case history and examination Case 1 A mother presented her second-born, very fractious 7-week-old infant to chiropractic practice reporting colic type symptoms since birth. She had previously consulted her general practitioner (GP) and health visitor who both stated, ‘‘he will grow out of it’’. Since birth, the infant had only slept for 25—45 min at a time, from which he would wake screaming and then continue to do so for 4—5 h. As if in pain, he drew his knees to his chest, turned red and became very rigid. These episodes especially occurred after feeding. The pregnancy was uncomplicated and, at full term, the mother gave birth vaginally with an epidural. Labour was prolonged, the head reported as being ‘‘engaged’’ for 16 h before the second stage of labour commenced, which failed to progress well though the duration was unknown. The foetus became distressed in the final hour, indicated by a low foetal heart rate recording. The foetus was a face presentation requiring forceps. At birth, left sided facial bruising was apparent as well as mild jaundice, the latter of which resolved within 24— 36 h. Both the 1- and 5-min Apgar scores were unremarkable. The infant had been breast-fed since birth, always appearing hungry and experiencing reflux. A change to formula-feed did not alter any symptoms. The sucking reflex was intact and the reflux was considered part of the symptom complex often associated with colic. On examination, the infant appeared healthy. A misshapen head was observed with an elongated anterior to posterior diameter and decreased transverse diameter. From a superior view, the frontal bone was more prominent on the left and the occiput more so on the right. The abdomen appeared bloated and, on examination, revealed focal tenderness in the right lower quadrant in the region of the ileocaecal valve, which caused the infant to scream. All neurological testing was unremarkable and appropriate for the infant’s age. Spinal examination revealed upper cervical (C1RP) and mid thoracic (T4 and T8) vertebral subluxation complexes (VSCs) and restricted motion in the right sacro-iliac joint (right posterior sacrum).
Case 2 The second case, a 10-week-old infant born to a nulliparous mother, presented with maternally diagnosed colic since 5—6 weeks old. Each episode typically lasted from 05.00 to 11.00 p.m. and similarly involved intense screaming with knees drawn
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to chest, red complexion and body rigidity. In association, non-projectile vomiting was reported every other day and, since birth, a preference to feed on the right breast was also noted with a bias towards left cervical rotation. He had been mainly breastfed, though, during the day, some formula feed was included in the diet. The evening feed tended to aggravate the symptom complex, though day feeds were uneventful. The infant slept well at night. A normal pregnancy was followed by a long labour reported to be 36 h in total. The mother’s prolonged first stage of labour required her to be induced and foetal delivery was complete 4 h later. The second stage of labour had also failed to progress due to the foetus getting stuck in the birth canal, which coincided with the occiput posterior (OP) malpresentation recorded. The Apgar scores were unremarkable, though the neonate was very quiet at birth and initially was unable to latch onto the nipple, not feeding for 24 h. The mother felt that he had been traumatised during the birth. On examination, the second infant similarly appeared healthy and had good weight gain. Although a subtle right rotation of the frontal bone with prominence on the left was detected, overall good head shape was observed. Tension was palpated in the diaphragms bilaterally but, on presentation, abdominal examination was otherwise within normal limits. Neurological testing was also unremarkable and appropriate for the infant’s age. Spinal examination revealed a similar pattern to the first infant; upper cervical (C1RP) and thoracic (T2— 4) VSCs and a posterior sacrum on the right.
Treatment methods and results In case 1, the infant received chiropractic treatment three times per week for 3 weeks. This consisted of diversified adjustment of C1, T4, and T8 and, occasionally, the right sacroiliac joint. Occipital decompression was also performed as well as a frontal lift and mobilisation of the right sphenoid. After 4 treatments, the colic symptoms had significantly decreased with no prolonged bouts of crying, improved sleep and the infant remaining calm after each feed. After 7 treatments, the reflux had completely resolved and, 3 weeks after the initiation of chiropractic care, the infant was sleeping for 10 h per night and was completely asymptomatic. Case 2 showed similar trends, though only 6 treatments were provided over a 21-day period, after which the infant was also asymptomatic. Despite a few reports of him being grizzly between 05.00 and 11.00 p.m. during the second week of treatment, no colic episodes occurred after the first treatment.
A.J. Hipperson
Resolution of the vomiting, hiccups and asymmetrical feeding was also achieved within the 6 treatments. Diversified adjustments were performed at C1, T2—4 (predominantly at T4) and to correct the right posterior sacrum. Cranial work involved occipital decompression and a frontal lift with left rotation. Soft tissue techniques were also used to relax psoas muscle and diaphragm tension bilaterally.
Discussion Cranial and spinal dysfunction was observed in both infants and, as suggested in the introduction, may result from the birth process10,33,34,37,63,78 and are considered subtle aspects of birth trauma, even in a ‘‘normal birth’’.8,10,12,42,45 At delivery, the first infant showed physical signs of birth trauma. Facial bruising is often associated with a face delivery.40,42,71 It may also be related to the application of forceps.39,40,71,72 The consequential moulding pattern in a face presentation produces a head shape termed ‘‘flattop’’40,42,73 or dolichocephaly.71 The presenting diameters are the submentobragmatic (9.5 cm) and bitemporal (8.2 cm) with the 11.5 cm submentovertical diameter distending the vaginal orifice in contrast to the ‘normal’ 9.5 cm diameter associated with the optimal occiput anterior presentation.40,71,74 Similarly, the OP presentation of the second infant will have resulted in presentation of an equally large 11.5 cm occipitofrontal diameter causing distension.40,71 Foetal malposition is considered responsible for improper cranial moulding10,38,42,75,76 and both malpresentations result in abnormal pressure being applied to the foetal cranium and spinal structures as well as producing cervical hyperextension, as opposed to the optimal flexion.40,42,71,76 The prolonged first stage of labour, with slow occurring effacement, may have contributed further to extension of the upper cervical complex, increasing the risk of cervical subluxation.12 Although the use of forceps on infant 1 involved significant traction upon the foetal head, risking damage to the upper cervical region,36,69 the manual force used to deliver a neonate in the absence of instrumental intervention will similarly apply traction,32,39,42 hence VSCs can still result from a ‘‘normal’’ delivery. Additionally, the prolonged labours may have caused excessive moulding, contributing to suboptimal cranial alignment and risking damage to the intracranial membranes.38,42,45,75 Excessive tension in these structures can affect cranial foramina diameters, causing aberrant cranial nerve function.37,45,79 The forceps required in the first birth will have further ‘jammed’ the cranial bones,
Chiropractic management of infantile colic
especially the sphenoids and occipital condyles38,42,45,75 the latter of which can distort the jugular foramen. This, it is hypothesized, can affect the vagus nerve, leading to varying gastrointestinal symptoms,38,42,45,73,75,79 commonly colic, diarrhoea and constipation.45,63,75,79 Amongst other trends, researchers have investigated whether a specific association exists between forceps and the development of colic. A recent study of 77 infants, reported a 4% higher incidence of forceps use in colicky infants compared to a non-colic group.77 Although the difference was not statistically significant, a similar trend was reported by Thomas.29 Despite the limitations involved in defining colic, many aspects of both presentations are similar to Illingworth’s15 colic criteria and the frequency of symptoms more than fulfils the criteria suggested by Wessel et al.24 Thus, for the purpose of this paper and for the point of comparison and discussion, the symptom complex of both infants may be deemed representative of colic. Diarrhoea and constipation are similarly difficult to define objectively and classifications vary, as do proposed aetiologies, many of which are dietary related.12,48 Chiropractic hypothesises that many gastrointestinal symptoms are due to spinal subluxation causing associated neuropathophysiology.6,8,12,20,37,41,44,45,48—54 At each spinal level, a spinal nerve consisting of somatic and visceral fibres exits. The latter constitute the ANS which itself is divided into sympathetic and parasympathetic fibres. The sympathetic fibres exit solely at the T1-L2 levels and thus are termed the thoraco-lumbar outflow. The parasympathetic fibres, termed the cranio-sacral outflow, exit at the levels of S2—4 and via cranial foramina of nerves III, VII, IX and X.55—61 Sympathetic stimulation relaxes the smooth muscle of the gastrointestinal tract (GIT) reducing peristaltic motion, stimulating contraction of sphincters and acting on a-receptors, causing vasoconstriction of the gastrointestinal blood supply and inhibiting bowel function. In contrast, parasympathetic stimulation facilitates bowel activity and motility of GIT contents by contracting gastrointestinal smooth muscle, relaxing sphincters and causing vasodilation.48,55—58,62 In theory, therefore, an imbalance within the sympathetic and parasympathetic components of the ANS may result in constipation or diarrhoea, a concept supported by several authors, though based on anecdotal evidence.37,45,48,49,63 The extension of this concept to embrace infantile colic is unproven, but consistent. This neurophysiological relationship between vertebral and ANS function is referred to by chiropractors as a somatovisceral reflex,41,44,48,52,58,64—67
183 alternatively termed a somato-autonomic reflex49,62 or somato-gastrointestinal reflex,68 a mechanism reported to be successfully demonstrated in several studies.33,50,51,62,66,70 A term more pertinent to chiropractic may be a spino-visceral reflex, a subset of somatovisceral reflexes.66 The results of this case series supports the existence of this reflex mechanism, but the importance of correct cranial alignment and motion is also emphasised, thus this paper proposes the more comprehensive term, spino-craniovisceral reflex. Nansel and Szlazak,70 having reviewed 350 articles, strongly debate the credibility of the somatovisceral theory, claiming that spinal dysfunctions merely create symptoms mimicking true internal visceral disease. Thus far, it is reasonable to hypothesise that, in both instances, the infant’s obstetric history is a causative factor for the spinal and cranial dysfunction recorded and, consequentially, may be, at least in part, the aetiology for their colic. The cervical dysfunction is proposed to affect vagal nerve output and, thus, gastrointestinal function.45,75,79 With the combination of cervical hyperextension, abnormal cranial moulding and, in the case of infant 1, forceps application, sub-optimal occipital alignment existed in both instances. This subsequently distorted the jugular foramen, through which the vagus nerve exits, thus, it is theorized, impacting upon the nerve45,75,79 and hence is a mechanism by which the ANS balance is potentially affected. The occipital decompression performed is therefore assumed to have facilitated the vagus nerve. The reported inability to latch on at birth (infant 2) also supports a degree of occipital compression, as a disrupted sucking reflex has been associated with jugular foramen distortion affecting cranial nerves IX and X and hypoglossal canal distortion causing interference to the hypoglossal nerve.38,42,45,63 The sympathetic trunks are located anterior to the transverse processes of the cervical vertebrae and the superior cervical sympathetic ganglion is at the C1—3 level.58,59 The author of this paper therefore proposes the hypothesis that an upper cervical rotational malposition or VSC may alter pressure upon the sympathetic ganglion, acting as an aberrant stimulation, thus inhibiting sympathetic output. The effect of cervical dysfunction may therefore not be solely on the parasympathetic portion of the ANS. The ileocaecal valve is relaxed by the parasympathetic nervous system.48 Therefore, this paper postulates that the cervical adjustments and occipital decompression performed on these infants could have reduced tension in this valve, improving gut motility, though the literature reviewed for this
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report did not make any reference to ileocaecal valve involvement. Stimulation of the sympathetics may also have occurred via adjustments to the thoracic spine, as previously discussed, hence the chiropractic treatments could have been said to have re-balanced the ANS rather than specifically targeted sympathetic or parasympathetics alone.
Conclusion These two cases suggest possible resolution of infantile colic though chiropractic management. It would appear that, in these two cases, there was an acceleration of the natural history (resolution at 3—4 months of age) of this self-limiting condition. The results support the existence of a somatovisceral reflex that, as stated, may be more aptly described as a spino-craniovisceral reflex. The proposed mechanism was facilitation of both the sympathetic and parasympathetic nervous systems aiding resolution of the symptoms by regaining the ANS homeostasis. The term ‘‘dysautonomia’’ has been used amongst the literature to refer to ANS imbalance, but this paper reserves this terminology for an actual dysfunction of the ANS, which is a clinical feature of several disease states. The limitation of case reports must be acknowledged, since results are not generalised and thus cannot be applied to the wider paediatric population. Additionally, absence of a control comparison means that placebo cannot be monitored, rendering results unreliable and extrapolation impossible. The parents and practitioner were not blinded to the treatment process, which introduces an inherent bias. The lack of diagnostic criteria for colic, subjectivity of palpation and reliance on parental reporting of symptomatic change as outcome measures, are additional limitations. The difference in demographic data and treatment frequency in the two cases presented should also be acknowledged. The need for more research into the effect of spinal manipulation upon the ANS and visceral function is evident and required if chiropractic is to become further accredited within the medical field, especially regarding treatment of visceral conditions such as colic. Anecdotal reporting does not suffice and larger-scale trials are required for adequate investigation of this phenomenon.
Acknowledgements The College of Chiropractors’ pre-registration training scheme of which this case series formed a part requirement.
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opractors Association; 1994. p. 11 [chapter 1]; p. 65—81 [chapter 4]; p. 106—10 [chapter 6]; p. 125—8 [chapter 7]. Hipperson AJ. The association between obstetric history and presenting symptoms of infants in chiropractic practice. BSc Chiropractic. England, UK: Anglo-European College of Chiropractic; 2001. Buchmann J, Bu ¨rungen ¨low B. Funktionelle Kopfgelenkssto und Tonusasymmetrie. Man Med 1983;21:56—62. Upledger JE, Vredevoogd JD. In: Upledger JE, Vredevoogd JD, editors. Craniosacral therapy, 1st ed. Seattle, WA, USA: Eastland Press; 1983. p. 111—5, 120—5 [chapter 7]. Hughes CA, Harley EH, Milmoe G, Bala R, Martorella A. Birth trauma in the head and neck. Arch Otolaryngol Head Neck Surg 1999;125:193—9.
CASE SERIES
Chiropractic management of infantile colic Andrea J. Hipperson Wight Chiropractic Clinic Ltd, 30 Roseburn Place, Edinburgh, EH12 5NX, Scotland, UK Received 1 August 2003; accepted 18 February 2004
KEYWORDS Chiropractic manipulation; Infantile colic; Paediatric human; Somatovisceral reflexes
Abstract Objective: To present two case studies in which the complete resolution of infantile colic and associated symptoms was achieved with chiropractic treatment. This case series supports the aetiological mechanism of an imbalanced autonomic nervous system, via somatovisceral reflexes secondary to regional cranial and spinal dysfunction. In addition, they provide support towards the birth process being a causative factor in the development of colic. Design: A case series. Setting: Private chiropractic practice. Subjects: The first case involved a 7-week-old male infant presenting with medically diagnosed colic, with associated reflux and disturbed sleep, all of which were persistent since birth. The second infant, aged 10 weeks, had suffered maternally diagnosed colic for approximately 1 month. Associated symptoms included some vomiting and asymmetry with breast-feeding. Both infants demonstrated many typical colic characteristics and had experienced birth trauma. Upper cervical, mid thoracic, sacroiliac and cranial dysfunction was recorded in both cases. Methods: Each infant received diversified paediatric chiropractic manipulation to the areas diagnosed as dysfunctional. Treatment was provided over a 3-week period, though the intensity differed for the two infants. Results: Complete resolution of all presenting symptoms was achieved in both instances. Conclusion: These cases suggest a possible association between birth trauma; the development of cranial and spinal segmental dysfunction and consequential manifestation of symptoms of infantile colic. Secondly, they demonstrate chiropractic treatment successfully restoring correct spinal and cranial motion, with an associated resolution of symptoms. ß 2004 The College of Chiropractors. Published by Elsevier Ltd. All rights reserved.
Introduction Paediatric patients commonly present to chiropractic practice with gastrointestinal symptoms. When considering bowel function, constipation and diarrhoea are located at opposite ends of a continuum, infants often fluctuating between the two. Colic, however, is seen as a separate entity, a paediatric condition of unknown aetiology,1—13 classically developing within the first 4 weeks of E-mail address: [email protected] (A.J. Hipperson).
life3,6,10,14,21 and spontaneously resolving by 3—4 months of age.3,5,10,16,18—23 This paper proposes that paediatric constipation, diarrhoea and colic can have a shared aetiology and are actually variations of the same condition: a gastrointestinal motility dysfunction due to an autonomic nervous system (ANS) imbalance. Two definitions of colic are most widely utilised. The first is the ‘‘rule of 3’’ in which the characteristic colicky cry lasts for more than 3 h per day, more than 3 days per week for a minimum of 3 weeks.24 The second is Illingworth’s15 ‘‘3 months colic’’. This
1479-2354/$30.00 ß 2004 The College of Chiropractors. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.clch.2004.02.003
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describes evening episodes of idiopathic, rhythmic crying, with associated facial redness, clenched fists, knees tightly drawn to the chest, flatulence and loud borborygmi up to 3 months of age. It must be appreciated that there is no standard diagnostic criteria for colic and thus studies adopt varying criteria rendering them incomparable in many instances.3,7,25,26 Theoretical discussions, proposed incidence, mechanisms of causation and management efficacy therefore almost certainly involve a heterogeneous group of infants with varying problems. Many aetiological factors for infantile colic have been explored amongst the literature including breast versus bottle-feeding, cows’ milk intolerance, parental anxiety, maternal demographic data, socioeconomic factors,2,7,10,16,17,22,23,26—28 parity, birth weight and other obstetric factors,1,3,4,13,15,29—31 but results have been conflicting and inconclusive. The chiropractic approach views colic symptoms as a consequence of the vertebral subluxation complex and cranial dysfunction, which can be sub-clinical entities resulting from peri-natal trauma or physical stress,33,34,37,73,76 the risk of which are greatly increased by several factors. These include in utero constraint; rapid or prolonged labour; foetal malpresentation such as occiput posterior, breech, face, brow or transverse delivery; assisted delivery using forceps, ventouse or manual traction and caesarean section.10,32,34,37,42,45,76,79 ‘‘Normal birth’’, which is generally considered absence of the previous obstetric factors, is not necessarily problem-free32—35 as distortional, compressive uterine forces will still be applied to the foetus regardless how ‘easy’ and uncomplicated the process.32,34,37 This alone can be responsible for foetal injury.38 Anecdotal reports show chiropractic spinal manipulation therapy to be successful in the treatment of infantile colic,6—8,10,12,20,42—45 as do limited clinical research trials.46 A 1989 study found that 94% of 316 cases of colic improved with chiropractic treatment.3 Placebo was not considered due to absence of a control group, but Wiberg et al.,31 excluded this limitation. Their randomised, controlled trial with a blinded observer showed chiropractic manipulation to be significantly more effective in the treatment of colic than the medical approach of Dimethicone (P ¼ 0:04, n ¼ 42) after only 4—7 treatments. The small sample number was still a limitation however and the parents were not blinded, thus a possible bias persists47 demonstrating the need for further research of this nature. These case reports demonstrate two infants relieved of colic by chiropractic treatment and discusses their birth processes as an aetiological factor and whether chiropractic may act to correct any resultant imbalance in the ANS.
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Case history and examination Case 1 A mother presented her second-born, very fractious 7-week-old infant to chiropractic practice reporting colic type symptoms since birth. She had previously consulted her general practitioner (GP) and health visitor who both stated, ‘‘he will grow out of it’’. Since birth, the infant had only slept for 25—45 min at a time, from which he would wake screaming and then continue to do so for 4—5 h. As if in pain, he drew his knees to his chest, turned red and became very rigid. These episodes especially occurred after feeding. The pregnancy was uncomplicated and, at full term, the mother gave birth vaginally with an epidural. Labour was prolonged, the head reported as being ‘‘engaged’’ for 16 h before the second stage of labour commenced, which failed to progress well though the duration was unknown. The foetus became distressed in the final hour, indicated by a low foetal heart rate recording. The foetus was a face presentation requiring forceps. At birth, left sided facial bruising was apparent as well as mild jaundice, the latter of which resolved within 24— 36 h. Both the 1- and 5-min Apgar scores were unremarkable. The infant had been breast-fed since birth, always appearing hungry and experiencing reflux. A change to formula-feed did not alter any symptoms. The sucking reflex was intact and the reflux was considered part of the symptom complex often associated with colic. On examination, the infant appeared healthy. A misshapen head was observed with an elongated anterior to posterior diameter and decreased transverse diameter. From a superior view, the frontal bone was more prominent on the left and the occiput more so on the right. The abdomen appeared bloated and, on examination, revealed focal tenderness in the right lower quadrant in the region of the ileocaecal valve, which caused the infant to scream. All neurological testing was unremarkable and appropriate for the infant’s age. Spinal examination revealed upper cervical (C1RP) and mid thoracic (T4 and T8) vertebral subluxation complexes (VSCs) and restricted motion in the right sacro-iliac joint (right posterior sacrum).
Case 2 The second case, a 10-week-old infant born to a nulliparous mother, presented with maternally diagnosed colic since 5—6 weeks old. Each episode typically lasted from 05.00 to 11.00 p.m. and similarly involved intense screaming with knees drawn
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to chest, red complexion and body rigidity. In association, non-projectile vomiting was reported every other day and, since birth, a preference to feed on the right breast was also noted with a bias towards left cervical rotation. He had been mainly breastfed, though, during the day, some formula feed was included in the diet. The evening feed tended to aggravate the symptom complex, though day feeds were uneventful. The infant slept well at night. A normal pregnancy was followed by a long labour reported to be 36 h in total. The mother’s prolonged first stage of labour required her to be induced and foetal delivery was complete 4 h later. The second stage of labour had also failed to progress due to the foetus getting stuck in the birth canal, which coincided with the occiput posterior (OP) malpresentation recorded. The Apgar scores were unremarkable, though the neonate was very quiet at birth and initially was unable to latch onto the nipple, not feeding for 24 h. The mother felt that he had been traumatised during the birth. On examination, the second infant similarly appeared healthy and had good weight gain. Although a subtle right rotation of the frontal bone with prominence on the left was detected, overall good head shape was observed. Tension was palpated in the diaphragms bilaterally but, on presentation, abdominal examination was otherwise within normal limits. Neurological testing was also unremarkable and appropriate for the infant’s age. Spinal examination revealed a similar pattern to the first infant; upper cervical (C1RP) and thoracic (T2— 4) VSCs and a posterior sacrum on the right.
Treatment methods and results In case 1, the infant received chiropractic treatment three times per week for 3 weeks. This consisted of diversified adjustment of C1, T4, and T8 and, occasionally, the right sacroiliac joint. Occipital decompression was also performed as well as a frontal lift and mobilisation of the right sphenoid. After 4 treatments, the colic symptoms had significantly decreased with no prolonged bouts of crying, improved sleep and the infant remaining calm after each feed. After 7 treatments, the reflux had completely resolved and, 3 weeks after the initiation of chiropractic care, the infant was sleeping for 10 h per night and was completely asymptomatic. Case 2 showed similar trends, though only 6 treatments were provided over a 21-day period, after which the infant was also asymptomatic. Despite a few reports of him being grizzly between 05.00 and 11.00 p.m. during the second week of treatment, no colic episodes occurred after the first treatment.
A.J. Hipperson
Resolution of the vomiting, hiccups and asymmetrical feeding was also achieved within the 6 treatments. Diversified adjustments were performed at C1, T2—4 (predominantly at T4) and to correct the right posterior sacrum. Cranial work involved occipital decompression and a frontal lift with left rotation. Soft tissue techniques were also used to relax psoas muscle and diaphragm tension bilaterally.
Discussion Cranial and spinal dysfunction was observed in both infants and, as suggested in the introduction, may result from the birth process10,33,34,37,63,78 and are considered subtle aspects of birth trauma, even in a ‘‘normal birth’’.8,10,12,42,45 At delivery, the first infant showed physical signs of birth trauma. Facial bruising is often associated with a face delivery.40,42,71 It may also be related to the application of forceps.39,40,71,72 The consequential moulding pattern in a face presentation produces a head shape termed ‘‘flattop’’40,42,73 or dolichocephaly.71 The presenting diameters are the submentobragmatic (9.5 cm) and bitemporal (8.2 cm) with the 11.5 cm submentovertical diameter distending the vaginal orifice in contrast to the ‘normal’ 9.5 cm diameter associated with the optimal occiput anterior presentation.40,71,74 Similarly, the OP presentation of the second infant will have resulted in presentation of an equally large 11.5 cm occipitofrontal diameter causing distension.40,71 Foetal malposition is considered responsible for improper cranial moulding10,38,42,75,76 and both malpresentations result in abnormal pressure being applied to the foetal cranium and spinal structures as well as producing cervical hyperextension, as opposed to the optimal flexion.40,42,71,76 The prolonged first stage of labour, with slow occurring effacement, may have contributed further to extension of the upper cervical complex, increasing the risk of cervical subluxation.12 Although the use of forceps on infant 1 involved significant traction upon the foetal head, risking damage to the upper cervical region,36,69 the manual force used to deliver a neonate in the absence of instrumental intervention will similarly apply traction,32,39,42 hence VSCs can still result from a ‘‘normal’’ delivery. Additionally, the prolonged labours may have caused excessive moulding, contributing to suboptimal cranial alignment and risking damage to the intracranial membranes.38,42,45,75 Excessive tension in these structures can affect cranial foramina diameters, causing aberrant cranial nerve function.37,45,79 The forceps required in the first birth will have further ‘jammed’ the cranial bones,
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especially the sphenoids and occipital condyles38,42,45,75 the latter of which can distort the jugular foramen. This, it is hypothesized, can affect the vagus nerve, leading to varying gastrointestinal symptoms,38,42,45,73,75,79 commonly colic, diarrhoea and constipation.45,63,75,79 Amongst other trends, researchers have investigated whether a specific association exists between forceps and the development of colic. A recent study of 77 infants, reported a 4% higher incidence of forceps use in colicky infants compared to a non-colic group.77 Although the difference was not statistically significant, a similar trend was reported by Thomas.29 Despite the limitations involved in defining colic, many aspects of both presentations are similar to Illingworth’s15 colic criteria and the frequency of symptoms more than fulfils the criteria suggested by Wessel et al.24 Thus, for the purpose of this paper and for the point of comparison and discussion, the symptom complex of both infants may be deemed representative of colic. Diarrhoea and constipation are similarly difficult to define objectively and classifications vary, as do proposed aetiologies, many of which are dietary related.12,48 Chiropractic hypothesises that many gastrointestinal symptoms are due to spinal subluxation causing associated neuropathophysiology.6,8,12,20,37,41,44,45,48—54 At each spinal level, a spinal nerve consisting of somatic and visceral fibres exits. The latter constitute the ANS which itself is divided into sympathetic and parasympathetic fibres. The sympathetic fibres exit solely at the T1-L2 levels and thus are termed the thoraco-lumbar outflow. The parasympathetic fibres, termed the cranio-sacral outflow, exit at the levels of S2—4 and via cranial foramina of nerves III, VII, IX and X.55—61 Sympathetic stimulation relaxes the smooth muscle of the gastrointestinal tract (GIT) reducing peristaltic motion, stimulating contraction of sphincters and acting on a-receptors, causing vasoconstriction of the gastrointestinal blood supply and inhibiting bowel function. In contrast, parasympathetic stimulation facilitates bowel activity and motility of GIT contents by contracting gastrointestinal smooth muscle, relaxing sphincters and causing vasodilation.48,55—58,62 In theory, therefore, an imbalance within the sympathetic and parasympathetic components of the ANS may result in constipation or diarrhoea, a concept supported by several authors, though based on anecdotal evidence.37,45,48,49,63 The extension of this concept to embrace infantile colic is unproven, but consistent. This neurophysiological relationship between vertebral and ANS function is referred to by chiropractors as a somatovisceral reflex,41,44,48,52,58,64—67
183 alternatively termed a somato-autonomic reflex49,62 or somato-gastrointestinal reflex,68 a mechanism reported to be successfully demonstrated in several studies.33,50,51,62,66,70 A term more pertinent to chiropractic may be a spino-visceral reflex, a subset of somatovisceral reflexes.66 The results of this case series supports the existence of this reflex mechanism, but the importance of correct cranial alignment and motion is also emphasised, thus this paper proposes the more comprehensive term, spino-craniovisceral reflex. Nansel and Szlazak,70 having reviewed 350 articles, strongly debate the credibility of the somatovisceral theory, claiming that spinal dysfunctions merely create symptoms mimicking true internal visceral disease. Thus far, it is reasonable to hypothesise that, in both instances, the infant’s obstetric history is a causative factor for the spinal and cranial dysfunction recorded and, consequentially, may be, at least in part, the aetiology for their colic. The cervical dysfunction is proposed to affect vagal nerve output and, thus, gastrointestinal function.45,75,79 With the combination of cervical hyperextension, abnormal cranial moulding and, in the case of infant 1, forceps application, sub-optimal occipital alignment existed in both instances. This subsequently distorted the jugular foramen, through which the vagus nerve exits, thus, it is theorized, impacting upon the nerve45,75,79 and hence is a mechanism by which the ANS balance is potentially affected. The occipital decompression performed is therefore assumed to have facilitated the vagus nerve. The reported inability to latch on at birth (infant 2) also supports a degree of occipital compression, as a disrupted sucking reflex has been associated with jugular foramen distortion affecting cranial nerves IX and X and hypoglossal canal distortion causing interference to the hypoglossal nerve.38,42,45,63 The sympathetic trunks are located anterior to the transverse processes of the cervical vertebrae and the superior cervical sympathetic ganglion is at the C1—3 level.58,59 The author of this paper therefore proposes the hypothesis that an upper cervical rotational malposition or VSC may alter pressure upon the sympathetic ganglion, acting as an aberrant stimulation, thus inhibiting sympathetic output. The effect of cervical dysfunction may therefore not be solely on the parasympathetic portion of the ANS. The ileocaecal valve is relaxed by the parasympathetic nervous system.48 Therefore, this paper postulates that the cervical adjustments and occipital decompression performed on these infants could have reduced tension in this valve, improving gut motility, though the literature reviewed for this
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report did not make any reference to ileocaecal valve involvement. Stimulation of the sympathetics may also have occurred via adjustments to the thoracic spine, as previously discussed, hence the chiropractic treatments could have been said to have re-balanced the ANS rather than specifically targeted sympathetic or parasympathetics alone.
Conclusion These two cases suggest possible resolution of infantile colic though chiropractic management. It would appear that, in these two cases, there was an acceleration of the natural history (resolution at 3—4 months of age) of this self-limiting condition. The results support the existence of a somatovisceral reflex that, as stated, may be more aptly described as a spino-craniovisceral reflex. The proposed mechanism was facilitation of both the sympathetic and parasympathetic nervous systems aiding resolution of the symptoms by regaining the ANS homeostasis. The term ‘‘dysautonomia’’ has been used amongst the literature to refer to ANS imbalance, but this paper reserves this terminology for an actual dysfunction of the ANS, which is a clinical feature of several disease states. The limitation of case reports must be acknowledged, since results are not generalised and thus cannot be applied to the wider paediatric population. Additionally, absence of a control comparison means that placebo cannot be monitored, rendering results unreliable and extrapolation impossible. The parents and practitioner were not blinded to the treatment process, which introduces an inherent bias. The lack of diagnostic criteria for colic, subjectivity of palpation and reliance on parental reporting of symptomatic change as outcome measures, are additional limitations. The difference in demographic data and treatment frequency in the two cases presented should also be acknowledged. The need for more research into the effect of spinal manipulation upon the ANS and visceral function is evident and required if chiropractic is to become further accredited within the medical field, especially regarding treatment of visceral conditions such as colic. Anecdotal reporting does not suffice and larger-scale trials are required for adequate investigation of this phenomenon.
Acknowledgements The College of Chiropractors’ pre-registration training scheme of which this case series formed a part requirement.
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