|There is an interest and sincerity, on the part of chiropractors, in reaching out to pediatric patients.
A second program – a 120-hour certification requiring one year to complete with an examination at the end – also began in 1994 through an independent group called the International Chiropractic Pediatric Association (ICPA). It, too, has developed into a well-known diplomate program and extended its required hours for completion. It can be achieved through the post-graduate education programs of certain chiropractic colleges.
More recently, a masters-level program has developed through Bournmouth University. This program, while focused on pediatrics, has a greater focus in the chiropractic research arena.
Finally, to assist in building an evidence base for pediatric chiropractic care, groups have been developing practice-based research networks (PBRNs) to systematically gather data from field practitioners.
When I speak to and/or teach groups worldwide, I find there is a genuine interest and sincerity, on the part of the chiropractors attending these classes, in reaching out to pediatric patients. We all want to be of service to this population. That being said, many DCs are still nervous about seeing children in their practices. What are the concerns expressed that hold my colleagues back from seeing children? How does one deal with these concerns?
QUESTIONS REGARDING PEDIATRIC PATIENTS
The top concerns I hear from DCs regarding treating pediatric patients are:
- What if I miss something?
- How do I obtain a thorough history on someone who cannot speak to me?
- How do I organize an examination, especially if dealing with a difficult case [read: infant temper tantrum]?;
- What outcomes do I use?
- How do I explain what I am seeing from a chiropractic perspective and remind the parent(s) I am not treating “x” condition but rather allowing the body to self-regulate and improve its own function?
- What is the safety record?
As with anyone serving in the health-care arena, we chiropractors have to consider the possibility of “missing something.” Despite systematic differential diagnoses, it is always possible to misdiagnose or delay a diagnosis of “something else,” regardless of what type of practitioner one is. In the pediatric population, serious health issues can go “bad” quite rapidly. We know this and are taught this. However, that being said, knowing the acceptable standards for normal, being diligent in your history and examination – that is, not taking shortcuts, putting it all together while considering differentials and seriousness – you should end up with a solid working impression.
My rule of thumb is to keep asking questions, using observation, physical examination, and our exceptional palpation skills, which, with appropriate testing if warranted, provides us with the necessary tools to make a solid diagnosis and formulate a plan.
At the end of the day, if a child is your patient, you need to care for him/her however you feel most appropriate. It goes without saying that if the child presents in a way that suggests there is an impending emergency, care for it as such and refer. If it is something outside our scope, yet there are chiropractic considerations, then refer to co-manage the patient. Keep to what we do best – let others do what they do best and follow up.
If you wish to gain more diagnostic testing beyond what we chiropractors can do, co-manage the patient with another health-care professional. Write a clinic note, to explain your findings and thoughts on what might benefit the child for further testing. Forward it to the appropriate professional and, then, follow up. I have done this when requesting genetic testing, advanced imaging (brain MRI, CT’s, ultrasounds) blood work, hearing, sight and dental tests, to name a few.
Another challenge faced is, “What if realize later that I’ve missed a test I should have done or should add to the arsenal of examination?” While it is best to know and remember your procedures so well that they are automatic, this does happen – often when you are distracted by questions from a parent or upon reflection of the file. Don’t despair – you can and should perform the tests on the next visit. Simply inform the parent at the report of findings that you are adding a couple of tests. Then, perform the tests, chart the results and move forward. I usually handle this with a comment along the lines of “I want to add a few more tests that I did not perform on the initial” or “ upon review, I realized I wanted more complete information on…” or “I was unable to obtain good information on this test on the initial so I wish to replicate that to determine
Ask ALL the right questions
Pediatrics can be challenging in that gaining information is done through the third party of the parent or guardian. In addition to the usual questions and systems review, I find an additional review of how this child is interacting and adapting in his/her environment helpful. Adding in age-appropriate questions on prenatal maternal health, birth, APGARs, feeding/appetite/nutrition, digestion/bowel function, urination, sleep cycles, milestones, social interaction with others, response, attention, activity, co-ordination, energy levels, style of care giving (home care, day care), among others, is very helpful in gaining an understanding of the child’s quality of life and fills in the blanks in building a good picture of the child’s history. This is an art but is learned through practice.
Kids will be kids
On occasion you may experience difficulty in completing your evaluation of a child. When this happens, it helps to know you have choices. Work through that visit as best you can and have the parent bring him/her back to complete the remainder of the examination at a different time or on a different day. I encourage chiropractors to meet the child where the child is at, not where we are at. This means we need to be flexible to adapt to the child at that time. If the child prefers to be examined while lying on the parent, so be it. If he/she prefers to be sitting, or on the floor, we can adapt to that too. We know how difficult it is to check ranges of motion in a tense child having a full-blown temper tantrum, or to gain a pediatric reflex at any time. We also recognize some findings may be “off” due to a child’s temporary behaviour. For example, a screaming child may have a reddened injected tympanic membrane, elevated respiration and heart rate. You can still gain much data but miss other elements. So come back to these at another time.
Also, as a rule of thumb, a well-fed, satiated infant is usually more compliant whereas a hungry infant is alert but perhaps more labile. An infant ready for a nap may be sleepy whereas one waking up may be cranky. A take-home lesson here is for us to be flexible to adapt to them, to meet them were they are at.
I recommend “cycles of care” when there comes a time to reassess the progress of the child in comparison to where they were and to re-establish new goals or changes for their care. It keeps us moving forward, looking for new issues that might have cropped up and measures the status of the child. It keeps us from dictating care based solely on the presence or absence of pain/symptoms, so care is based on clinical findings. The time to reassess may be dictated upon a visible change, either positive or negative, in clinical status; when thinking about changing technique, frequency of visits, etc; and when thinking about adding something else to the program of care, if there is information regarding new complaints/trauma or based on certain time frames. The purpose, of course, is to globally document how the child is progressing.
The reassessment, if comparing to the initial assessment, should retest the same components. I personally look at the health status from a global perspective – osseous, muscular, soft tissue, neurological function, growth and development. Basic physiological tests such as vitals are also helpful to recheck.
In addition, I utilize forms that parents complete at each reassessment. These forms address their observations and offer scales for them to rank how their child is doing in 12 areas of life. Forms also allow them to complete lifestyle questions regarding the child’s stress, nutrition, and any traumas that have occurred, either previous to, or during, the time of treatment. From a standpoint of gaining information and addressing any unanswered questions, these forms are invaluable and, again, add to my certainty regarding care strategies for the patient.
The idea behind all of this is to address the clinical question of why the child is attending for care. Gathering evidence through the history and examination, arriving at a hypothesis – diagnosis – delivering care and then measuring the outcome is the living application of the scientific method.
In part 2, I will address how to maintain the conversation within the chiropractic scope of practice. While deviating into other areas may be of utility to you as a clinician, if misinterpreted this may confuse the
patient and parents regarding what we do, as well as be misconstrued as delivering care in areas outside our scope. I will also address the safety record of infant care and chiropractic.
Dr Liz Anderson-Peacock’s extensive background includes a multi-decade chiropractic practice that ranks, globally, in the top percentile in terms of volume and best practices; articles in peer reviewed journals; membership on academic panels; and involvement with regulatory boards. She has taught pediatrics for numerous colleges and groups throughout the world and graduated first in the ICA/ACA pediatric diplomate program in 1996. She‘s the recipient of numerous awards and currently delivers keynote lectures and workshops, as well as coaches professionals in the co-operative model.