J Manipulative Physiol Ther 2009 (Oct); 32 (8): 670–674
Joyce E. Miller, DC, Ann-Kristin Sulesund, Andriy Yevtushenko
Advanced Professional Practice Chiropractic Paediatrics, Bournemouth University, Bournemouth, UK. email@example.com
OBJECTIVE: The purpose of this study was to describe the circumstances, clinical features, role, and results of chiropractic management of infants who were referred to a chiropractic clinic for failure to adequately feed at the breast.
METHODS: Clinical case series of 114 infant cases of hospital-diagnosed or lactation consultant diagnosed feeding problems that were treated with chiropractic therapy in addition to routine care and followed to short-term result.
RESULTS: The most common age of referral was 1 week (mean, 3 weeks; range, 2 days-12 weeks), and the most common physical findings were cervical posterior joint dysfunction (89%), temporomandibular joint imbalance (36%), and inadequate suck reflex (34%). Treatment was chiropractic therapy in addition to any support given elsewhere. All children showed some improvement with 78% (N = 89) being able to exclusively breast feed after 2 to 5 treatments within a 2-week time period.
CONCLUSIONS: Cooperative multidisciplinary care to support breastfeeding was demonstrated in this population. Chiropractic treatment may be a useful adjunct to routine care given by other professionals in cases of diagnosed breastfeeding problems with a biomechanical component.
From the Full-Text Article:
Although none of the infants were presented specifically for birth trauma, almost 14% had frank signs of birth trauma and it has been proposed that bruising and trauma to the infant's cranium, face and spine during birth can lead to feeding difficulties. [14, 15] Although it is difficult (if not impossible) to precisely establish exact reasons for feeding problems in the infant, assisted births such as forceps, vacuum extraction and cesarean sections have been implicated. For example, vacuum extraction has been shown to be a strong predictor of early cessation of breastfeeding.  In the present case series 10.4% of the experimental group experienced a vacuum extraction delivery compared to the 4.3% average reported for 3 local hospitals. 
Likewise, forceps delivery may exert excess pressure on cranial bones, which may alter symmetry of the cranium and/or jaw causing poor suck function in the baby.  Forceps were used in 19.1% in this population compared to 3.9% in the local hospital averages. 
Because 68% of these infants were first-born, it can be said that this may be linked to the increased likelihood of delivery complications in primaparas as well as being linked to inexperienced mothers who may have a more difficult time with breastfeeding.  Prematurity was not an issue as all infants were born full term.
Infants in this cohort had been seen by various health care practitioners which included one or more of the following: midwife, lactation consultant, pediatrician, general practitioner, feeding consultant and/or chiropractor. Infant feeding is seen as an urgent problem with no single answer. All professionals with skills in this arena are called upon to assist and cooperation is the rule rather than the exception. All of these infants had had pertinent investigations for pathology and extensive training with lactation consultants and/or midwives prior to referral for chiropractic care. Chiropractic skills fit into the realm of manual therapy to treat biomechanical problems. Once the feeding problems were determined not to be pathological, genetic, or maternal in origin, care by a manual therapist was appropriate. The young age of the children who were referred (1 week of age was the mode) may suggest that health care professionals are cognizant of the care, which is available and appropriate and recommend that care for the infant.
Our one specific outcome measure was ability to exclusively breastfeed (with maintenance of weight gain). We did not use any of the common rating instruments as they have not been validated in any controlled manner. [16, 19] Mothers were also given the opportunity to rate the improvement on a 10-point scale, so that they could record partial improvement, no improvement or worsening. At first glance, it seems that all of the infants improved somewhat in their ability to breastfeed. However, with exclusive breastfeeding as the primary outcome measure, it was simple to determine an exact success rate but impossible to credit that success to any specific modality of treatment. The degree of improvement that was related to the natural course of the condition as well as the maternal commitment and effort versus how much could be attributed to chiropractic intervention and/or support from lactation consultants cannot be established. Maturity of the infant, healing of injury or the effects of medication wearing off could result in an improvement in feeding without intervention.  That said, no child can be left to flounder whilst waiting for the natural history to take its course.
Not all of the infants graduated to exclusive breastfeeding. This can be seen as failure since exclusive breast feeding is the goal set by the World Health Organization  as well as the clinicians and parents involved. Twenty per cent of the infants (N = 23) had to be bottle-fed which often means with manufactured milk. It has been shown that early introduction of any artificial milk is associated with further decline in the use of mother's milk for the infant. 
There were several limitations, some of which are inherent in a case series. This type of study, by its definition, cannot determine efficacy of the therapy given. A randomized controlled trial is the best way forward to determine conclusively whether manual therapy is a viable option to assist these mother-infant dyads to achieve exclusive breastfeeding.
Another weakness in this study is the lack of long-term follow-up. Exclusive breastfeeding to 6 months of age is recommended by the World Health Organization.  In addition, there were multiple sources of birth information including parental report and hospital records, leaving room for error in data recall. Examination procedures were standard but may have been executed differently by multiple examiners. All infants either were concurrently or had been under care of other professionals, and there was no standardization of their contribution to the treatment of the infant.
Feeding difficulties in an infant are fraught with stress for the infant and the family. All professionals seek to support the mother/infant dyad in successful breastfeeding. There are several case studies, which suggest that a chiropractic approach to this issue may be useful. [14, 22–24] This study sought to discover any unique characteristics of infants presenting with breastfeeding problems and whether chiropractic care offered any benefits within the milieu of wider health care. Two points can be highlighted. First, there was a higher than average rate of birth intervention in this cohort, suggesting one possible etiology for a biomechanical problem. Second, given that all of these patients were sent by other health care professionals, there was a recognition that biomechanics may be part of the problem and that a chiropractic approach might be efficacious. Further higher-quality studies are required to determine whether this is the case.
This case series found that in a population of 114 infants referred by a medical practitioner to chiropractors for feeding difficulties, 89 (78%) were exclusively breast fed after 4 treatments. It is not known whether this is a result of chiropractic manual treatment, the cotreatment provided along with other health care providers or the natural course of this condition. Cooperative care may go some way forward to meet the enormous challenge of exclusive breastfeeding as a goal in developed populations where breastfeeding initiation is high but numbers rapidly decline after the first week.
Infants with suboptimal breastfeeding are at higher risk of being artificially fed which may create short and long-term problems for the child, the mother, and society.
Suboptimal infant breastfeeding is recognized early by medical professionals who are in a prime position to refer for adjunctive care in a cooperative effort to solve the problem.
- For infants in this study, routine care plus chiropractic care resulted in the ability of 78% of infants to exclusively breastfeed.
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