Breastfeeding Difficulty

The benefits of breastfeeding are many. They include: nutritional, immunological, cognitive, decreased morbidity and mortality, analgesic effects, decreased costs (products, healthcare), decreased risk of allergy, and improved jaw development and dentition(1). Exclusive breastfeeding is recommended as the best form of feeding in the first six months(2).

60% of mothers who cease breastfeeding do so earlier than desired. There are numerous reasons why mothers stop breastfeeding. These include maternal and infant factors, as well as societal and environmental factors. Infant related factors are important reasons for breastfeeding cessation with reported trouble sucking or latching (26%), self-weaning (26%), nipple problems (20%), and pain (15%) being significant contributors(3).

These infant factors may have a secondary effect on other important factors such as perceived milk supply, perceived satisfaction, maternal pain, maternal confidence, and desire to continue. For example, studies have shown that milk stasis is the primary dysfunction in mastitis, and that attachment and side preference is the most significance contributor to milk stasis(4).

There have been numerous case reports showing the benefits of chiropractic care for those with breastfeeding difficulties.

One case series study looked at the response to chiropractic care of 114 infants with suboptimal breastfeeding(5). All showed some improvement, with 78% of the group able to exclusively breastfeed within 2-5 visits and within 2 weeks. The most common physical findings were cervical posterior joint dysfunction (89%), temporomandibular joint (TMJ) imbalance (36%), and inadequate suck reflex (34%).

Dr Adam Stewart has completed a study at Chiropractic Children’s Healthcare on 19 mothers and their babies with breastfeeding difficulties(6). In a group of infants, Dr Adam sought to establish:

1. What was the response to chiropractic care?

2. What percentage of infants had subluxation (joint dysfunction), and what where the specific subluxation patterns?

3. What are the specific effects of certain patterns on breastfeeding behavior?

There were improvements in breastfeeding in every patient. Improvements occurred in every characteristic monitored. The most significant areas of improvement occurred with attachment to the breast (100%), arching (94%) and shaking (88%) once attached, overall stress of feeding (84%), pain when feeding (77%), and side preference (64%). The most common problems occur at the upper cervical, shoulder, sacral, elbow and wrist regions (6). TMJ and cranial dysfunctions are also commonly involved. The next step is to obtain funding for a case series study on 80-100 babies.

Common Indicators:

Difficult attachment

Arching (extension) type movements of the neck/body when trying to latch. This can occur on both sides (bilateral), or only one side (unilateral). These babies are often unsettled, have poor swallow, and/or a head preference/head asymmetry/plagiocephaly. Other symptoms may appear "reflux" like.

Arching or shaking fussiness

Once attached, two specific patterns may occur.

1. Arching (extension) movements as described above, or

2. Side-to-side (shaking) movements. Arching on one side and shaking on the other can occur. Babies with the shaking pattern will often have poor sleep regulation (poor settling and frequent waking).

General Fussiness

General fussiness occurring only on one side with pain, crying and pulling off, which starts after attachment and continues throughout the feed. These babies are often unsettled, with poor sleep, hate/dislike tummy time and dressing. Poor suck and swallow Suck dysfunction may include poor tongue movement, mouth movement, rooting/sucking reflexes, and clicking noises. A very strong suck (the “chomper”) that hurts the nipple can occur due to pain. Other signs include excessive choking, gagging and coughing. Falling asleep at the breast Certain specific problems can affect arousal levels, thus affecting full completion of feeds.

A combination of multiple patterns

The above patterns are typical of specific body dysfunctions, and when only one dysfunctional area is present, the pattern is relatively simple to identify. It is very common to have multiple combinations of these patterns, or variations of these patterns, which must be recognised for resolution of the breastfeeding difficulty, and thus continuation of feeding.

Other problems

Problems such as mastitis, tongue-tie, low milk supply, and maternal stress complicate the breastfeeding process, and these issues may need to be addressed concurrently. Referral for lactation consultant or maternal child health nurse advice is often required.

References:

1. Leung, A. and R.S. Sauve, Breast is Best for Babies. Journal of the National Medical Association, 2005. 97(7): p. 1010-1019.

2. WHO, The Optimal Duration of Exclusive Breastfeeding, Report of the expert Consultation of the Optimal Duration of Exclusive Breastfeeding, Geneva, Switzerland, March, 2001.

3. Odom, EC et al. Reasons for Earlier Than Desired Cessation of Breastfeeding Pediatrics 2013;131:e726-e732

4. WHO, Mastitis; Causes and Management, Department of Child and Adolescent Health and Development, Geneva, 2000

5. Miller, J.E., et al., Contribution of Chiropractic Therapy to resolving suboptimal breastfeeding: A case series of 114 infants Journal of Manipulative and Physiological Therapeutics, 2009. 32(8): p. 670-674.

6. Stewart A. Paediatric Chiropractic and Infant Breastfeeding Difficulties: A pilot case series study involving 19 cases. Chiropr J Aust: 2012 Sept 2012 (42:3): 98-107

Plagiocephaly or Head Asymmetry

What causes head asymmetry?

Head asymmetry can be evident from birth in about 13% of babies due to in utero moulding of the shape of the baby’s head; in most cases rapid correction of the baby’s head shape occurs soon after birth. Most cases of head asymmetry develop after birth becoming apparent to the parents or to a health care professional between four to eight weeks of age. The head asymmetry typically affects one side of the occipital bone or the back of the head. The issue of head asymmetry has become more common as a result of the baby on the back program to reduce the incidence of SIDS.

Head asymmetry is caused by constant pressure on one part of the back of the head and this tells us that the baby is not able to turn their head properly to both sides resulting in positional preference. Babies that develop head asymmetry have been found to have a positional preference and to also have restricted neck function.

Our clinical experience at Chiropractic Children’s Healthcare indicates that most of the cases we see with occipital plagiocephaly have dysfunction affecting the upper cervical spine. Chiropractors specialise in and are specifically trained to correct this type of issue when it affects the cervical spine.

What is the long term effect of plagiocephaly or head asymmetry?

Prior to the year 2000 the general opinion within the medical community was that there were no long term issues with head asymmetry as it was just cosmetic. This belief was shown to be incorrect as a result of research published in 2000, which found that 39.7% of the children with persistent deformational plagiocephaly had received special help in primary school. Only 7.7% of siblings required similar help. Problems noted related to subtle problems of cerebral dysfunction that were manifest during the school age years involving language disorders, learning disability and attention deficits.(1) This was confirmed by in 2007 by research which reported that 33% of the cases diagnosed with deformational Plagiocephaly in infancy went on to need learning assistance with 14% in special class. Long term outcomes were no different between with or without helmet use. (3)

In 2002, research found that most of the infants with Plagiocephaly had impaired central sound processing and have an elevated risk of auditory processing disorders. (4) Then in 2005, research found that 35% of infants with deformational plagiocephaly had altered visual field development. (5) Unfortunately many are unaware of this research and continue to regard occipital plagiocephaly as a cosmetic issue requiring no treatment or management.

What is the short term effect of plagiocephaly or head asymmetry?

In 2001, research was published which this time looked at the short term effects of head asymmetry (6). The group with plagiocephaly were tested at an average age of 8 months, 0% of the subjects in the plagiocephaly group were accelerated, 67% were normal, 20% had mild delay and 13% had significant delay. This study indicates that before any intervention, babies with plagiocephaly demonstrate delays in cognitive and psychomotor development by an average of 8 months of age.This was confirmed in 2009 by research looking at 287 infants with deformational Plagiocephaly and found that 36% showed developmental delay. (7)

We can see from this research that occipital plagiocephaly is associated with cognitive and psychomotor developmental delays in 33% of babies by 8 months of age and that this can persist resulting in 39.7% of children with persistent occipital plagiocephaly going on to experience learning difficulties and attention deficits when attending primary school.

Does helmet therapy help plagiocephaly or head asymmetry?

Helmet use improves the head shape of babies with plagiocephaly and helmet therapy is being used up to 18 months of age with the best result obtained prior to 12 months of age. However, the research has indicated that the use of helmets did not alter the long term issue with learning difficulties: about 40% of the helmet group later experiencing learning difficulties which was the same percentage as the untreated group.(1) Using helmets on their own will improve the head shape but will not alter the associated problem of brain development in babies with plagiocephaly.

How is plagiocephaly managed?

Home positional managment of the infant involving enouraging the infant to spend time with the head turned to the non flat side when supine is important to help the head shape improve. Poorly responsive or more severe case of head asymmetry may be referred for helmet therapy. If there is involvement of the neck muscle (such as a sternocleidomastoid tumor) then stretching exercises are usually part of the program of care. It is important to resolve any issue regarding muscle contracture as early as possible to minimize the possibility of later need for surgical correction of the muscle issue.

References:

1. Miller, R. I. and S. K. Clarren (2000). "Long-Term Developmental Outcomes in Patients With Deformational Plagiocephaly." Pediatrics 105(2): e26-

2. Slate RK, Posnick JC, Armstrong DC, et al: Cervical spine subluxation associated with congenital muscular torticollis and craniofacial asymmetry. Plast Reconstr Surg 1993;91:1187-1197.

3. Steinbok P, Lam D etal. Long-term outcome of intants with positional occipital Plagiocephaly. Child Nerv Syst (2007) 23:1275-1283

4. Balan P, Kushnerenko E, et al. Auditory ERPs Reveal Brain Dysfunction in Infants with Plagiocephaly. Journal of Craniofacial Surgery (2002) 13(4):520-525

5. Siatkowski RM, Aaron CF et al. Visual field defects in Deformational Posterior Plagiocephaly (2005) Journal of AAPOS 9(3):274-278

6. Neurodevelopment in Children with Single-Suture Craniosynostosis and Plagiocephaly without Synostosis. (Plast. Reconstr. Surg. 108: 1492, 2001.)

7. Hutchinson BL, Alistair WS et al. Characteristics, head shape measurements and developmental delay in 287 consecutive infants attending a Plagiocephaly clinic. Acta Paediatrica (2009) 98(9):1494-1499

Sleeping Difficulty

 Why is sleep important?

Sleeping difficulties are a common childhood complaint with up to 40% of children experiencing sleep problems at some point in their development (1) (2). This can become disruptive to the whole family unit, as regular night waking requires parent intervention to fall back to sleep. Sleep itself is a crucial part of human physiology – and there are many theories as to why it is that we sleep. From protection to regeneration and restoration, there are many aspects of sleep that aid us in our day-to-day living. Recent research has come to highlight the importance of sleep in regards to memory function and learning. Adults use sleep to consolidate facts and knowledge during slow-wave sleep and motor skills during rapid-eye-movement (REM) sleep state. Children, however, will prioritise consolidating facts and knowledge over motor patterns. There is a strong link between sleep quality and quantity with daytime cognitive and behavioural performance (1). This was highlighted in a study showing that persistent reduction of just one hour of a child’s sleep at 40 months of age can impact on their academic performance at 6 years of age. This further adds to the growing body of evidence showing the importance of developing and maintaining healthy sleeping patterns on later behaviour and academic performance (3).

Source: Nelson’s Textbook of Pediatrics, 19th Edition

How much sleep should my child be getting?

Source: Nelson’s Textbook of Pediatrics, 19th Edition

Initially, a child has higher sleep requirements; up to 16 hours in a 24-hour period, equally divided between day and night sleeps. A newborns’ sleep cycle is initially dependant on feeding, with night waking for feeding every 2-3 hours with the occasional 5-hour cycle (4), and day sleep cycles being split into four equal naps typically of 2 hours each. By six months of age, a child’s night sleeping patterns begin to resemble that of an adult and do not require regular overnight feeds (2) (5). It was in fact shown that by decreasing regular night-waking for feeds that breastfeeding was able to continue for longer. The total number of hours that a child sleeps continues to decrease over time, reducing to 12 hours at 3 years of age (2). Day sleeps also gradually decrease; reducing to one day nap at 18 months of age before phasing out the day nap by 4 years of age (6).

What could be disturbing my child’s sleep?

• Cow’s Milk Protein

• Nocturnal Enuresis/Bed-wetting

• Night Terrors/Nightmares

• Obstructive Sleep Apnoea

• Snoring

• Dermatitis/Eczema

• Colic

• Excessive screen time/electronic device use

• Excessive stimulation

• Early School times

• Homework overloading

Cow’s Milk Protein 
A sensitivity to cow’s milk protein has been associated with colicky presentations in the newborn, and removal of cow’s milk protein from the infant diet in a study in 2006 resulted in improvement of sleeping patterns in almost 85% of candidates (2) (7).

Nocturnal Enuresis
Nocturnal Enuresis, or bed-wetting, is the involuntary voiding at night, and affects up to 20% of children at 5 years of age (6). This may be a reflection of brain maturity, as it has been shown that children who lag developmentally at one and three years of age, are more likely to have enuresis at 6-years of age (2).

Night Terrors
Commonly in children aged 3-8, night terrors tend to occur more during times of stress or, ironically, fatigue. Terrors involve the child sitting up, screaming inconsolably for up to 30 minutes during which time their heart is racing, breathing rapid, and may have other autonomic dysfunctions such as sweating or altered temperatures occurring (2). There are suggestions that night terrors are also a result of brain immaturity and being unable to process the days’ events.

Obstructive Sleep Apnoea
Thought to affect 1-3% of children, Obstructive Sleep Apnoea is commonly detected in children by snoring, difficulty breathing, or mouth-breathing while asleep. One major cause is adenotonsillar hypertrophy, or enlarged tonsils, common among children with recurrent infections, allergies, intolerances or sensitivities (such as Cow’s Milk Protein senstivity) (2).

Atopic Dermatitis
Dermatitis, such as eczema, is thought to have a two-fold effect on sleep behaviours; firstly, the itchiness of the skin and scratching can interrupt sleep, and secondly, by interactions between the immune system and circadian cycles promoting wakefulness (8).

Lifestyle Factors (early school start times, homework levels, busy evenings, electronic device use)
There are numerous studies that show the impact of lifestyle factors on sleep, but one of the most impacting and researched is that of electronic media (1)(Many more references available on request). The majority of screens that we use on our electronic devices act on inhibiting or reducing melatonin production – the hormone that is essential for falling asleep.

Colic 
Colic, or persistent crying, is experienced in up to 21% of infants, and is the most common complaint for a parent to seek professional advice (9). Recent literature suggests one potential cause of colic is musculoskeletal discomfort, resulting in inappropriate behaviours such as disrupted sleep (10).

DOES YOUR CHILD TAKE MORE THAN 30 MINUTES TO FALL ASLEEP?

DOES YOUR CHILD WAKE MORE THAN ONCE IN THE NIGHT?

DOES YOUR CHILD SNORE?

IS YOUR CHILD VERY RESTLESS AT NIGHT?

This is how chiropractic may be able to help.

Chiropractic may be able to help restore proper spinal and nervous system function. Research has indicated that by improving a child’s spine and nervous systems that they had a noticeable improvement in sleep duration, reduced night-waking, and a reduced length of time required to fall asleep(9) (10) (11) (12). This has been attributed to reduction of pain or discomfort experienced by the child, improved feeding quality, improved biomechanics of the spine and musculoskeletal system and improvement in the neurological function of the child.

At Chiropractic Children’s Healthcare, we begin with an initial consultation that incorporates a thorough assessment which would aim to establish potential causes of the interruption to your child’s sleep. This will help to determine the best treatment of any spinal or musculoskeletal conditions, as well as providing appropriate management for any other causes of sleeping problems. This management ultimately may help to promote more positive long-term outcomes, as well as a happier and healthier child.

REFERENCES

1. Novel mechanisms, treatments and outcome measures in childhood sleep.Colonna, Annalisa, et al. 2015, Frontiers in Psychology.

2. Sleep Disorders and Sleep Problems in Childhood. Thiedke, C. Carolyn. 2001, American Family Physician, pp. 277-84.

3. Associations Between Sleep Duration Patterns and Behavioral/Cognitive Functioning at School Entry. Touchette, Evelyne, et al. 2007, Sleep, pp. 1213-1219.

4. Australian Breastfeeding Association. Do I need to wake my baby for feeds?Australian Breastfeeding Association. [Online] August 2012. https://www.breastfeeding.asn.au/bfinfo/do-i-need-wake-my-baby-feeds.

5. Help Me Make It Through the Night: Behavirol Entrainment Breast-Fed Infants' Sleep Patterns. Pinilla, Teresa and Birch, L. Leann. 2, s.l. : Pediatrics, 1993, Vol. 91, pp. 436-444.

6. Kliegman, Robert M., et al.Nelson Textbook of Pediatrics (19th Edition).Philadelphia : Elsevier Saunders, 2011.

7. Chiropractic Management of Cow's Milk Protein Intolerance in Infants With Sleep Dysfunction Syndrome: A Therapeutic Trial. Jamison, Jennifer R. and Davies, Neil J. 2006, Journal of Manipulative and Physiological Therapeutics, pp. 469-474.

8. Mechanism of Sleep Disturbance in Children with Atopic Dermatitis and the Role of the Circadian Rhythm and Melatonin. Chang, Yun-Seng and Chiang, Bor-Leun. 2016, International Journal of Molecular Science, pp. 462-473.

9. Long-Term Effects of Infant Colic: A survey comparison of Chiropractic treatment and nontreatment groups. Miller, Joyce E. and Phillips, Holly Lane.2009, Journal of Manipulative and Physiological Therapeutics, pp. 635-638.

10. Management of musculoskeletal dysfunction in infants. Yao, Dan, Deng, XingQiang and Wang, MingGuang. 2016, Experimental and Therapeutic Medicine, pp. 2079-2082.

11. Chiropractic care of a pediatric patient with symptoms associated with gastroesophageal reflux disease, fuss-cry-irritability with sleep disorder syndrome and irritable infant syndrome of musculoskeletal origin. Alcantara, Joel and Anderson, Renata. 2008, Journal of the Canadian Chiropractic Association , pp. 248-255.

12. Osteopathic Manipulative Treatment for Pediatric Conditions: A Systematic Review. Posadzki, Paul, Soo Lee, Myeong and Ernst, Edzard. 2013, Pediatrics, pp. 140-152.

Unsettled/Irritable Infants

Unsettled/Irritable Infant 

The Irritable Baby

Infantile colic is a term that has been used by various healthcare professions to describe the persistent, often violent crying which sometimes characterizes an otherwise healthy and thriving baby. There has never been agreement about how to diagnose colic with the result that the term colic is applied to many different clinical presentations. Colic also carries an inference that the cause of the symptoms is in some way due to abdominal or intestinal problems: no link with the intestines as a cause of the symptoms has been found and the cause of the symptoms remains unknown. In view of these difficulties we prefer to use the diagnosis "Irritable Baby Syndrome" (IBS). Numerous non chiropractic treatments have been proposed but most have been shown to be without effect and most drug preparations have serious side effects. A common drug treatment still used is dimethicone and several good controlled studies have shown that this treatment is no better than placebo.

There are a number of conditions that can complicate IBS. It is important that the baby has a full examination by someone trained in paediatrics to rule out the possibility of other underlying disorders such as cow’s milk protein or soy protein sensitivity, infection, gastroesophageal reflux, pyloric stenosis, intussusception or a bowel obstruction. In the absence of any of other causative conditions the baby is regarded as having “uncomplicated colic”.

Cow’s milk protein sensitivity:

The clinical diagnosis of cow’s milk protein intolerance is made based on the presence of the “triad” of symptoms, which include gastrointestinal disturbance, skin rash and respiratory ‘wet’ sounds. (5) Cow’s milk protein allergy/intolerance is the main cause of lactose intolerance in infants. Common symptoms associated with cow’s milk protein intolerance are:

Gastrointestinal: Bloating, frequent passage of flatus and intractable crying/distress with pulling up of the legs. Chronic diarrhea, constipation or an alternating pattern of both.

Skin: Maculopapular rash which may occur anywhere on the body but is most commonly found on the face neck trunk buttocks and upper arms. Eczema.

Respiratory: Crackles/wet sounds without obvious dyspnea. Wheezing and rhinitis (snuffly breather).

Neurological: Disturbed sleep pattern with frequent waking and crying at night.

At Chiropractic Children’s Healthcare, safety and specificity are our top priorities. Our treatment of children is extremely gentle with an exemplary safety record.

References:

1. Klougart N, Nilsson N, Joacobsen J. Infantile colic treated by chiropractors: a prospective study of 316 cases. JMPT 1989;12(4):281-8.

2. Wiberg JMM, Nordsteen J, Nilsson N. The Short-term Effect of Spinal Manipulation in the Treatment of Infantile Colic; A Randomised Controlled Clinical trial with a Blinded Observer. JMPT 1999;22(8):517-522.

3. Wiberg KR and Jesper MM. A retrospective study of chiropractic treatment of 276 Danish infants with infantile colic. J Manipulative Physiol Ther 2010;33:536-541

4. Miller JE, Newell D, Bolton JE. Efficacy of chiropractic manual therapy on infant colic: a pragmatic single blind, randomized controlled trial. J Manipulative Physiol Ther 2012;35:600-607

5. Davies NJ. Chiropractic Pediatrics: A Clinical Handbook. Churchill-Livingstone. 2000