An understanding of bronchial asthma depends upon an understanding of the anatomy from the trachea down to the terminals of the bronchioles. The outer trachea is composed of 16 to 20 connective tissue-covered cartilaginous rings. These crescent-shaped rings open posteriorly. The ends of the rings are attachment points for the trachealis muscle. This smooth muscle membrane contracts to narrow the tracheal lumen during coughing or upon forced expiration. Internally is a layer of nerves and mucus-secreting goblet cells in a connective tissue mesh. This layer has an epithelial lining that forms the inner wall of the lumen (31).

The bronchi branch left and right from the caudal aspect of the trachea to enter their respective lungs. These further subdivide into progressively smaller and more numerous bronchi, up to 10 orders of subdivision. The cartilage layer forms part of the structure of the bronchi, although at the later divisions it exists as plates and then rods. These are joined together by a smooth muscle and connective tissue network, which contains nerves, blood vessels, and lymphatic vessels. The lumen is lined with ciliated epithelium (31).

The bronchioles form the 11th and further orders of subdivision. Cartilage stops at this level. Elastic connective tissue and smooth muscle forms the walls of the bronchioles. Alveolar ducts branch off of the furthest sub-branches of the bronchioles. The alveolar ducts further subdivide into smooth muscle-walled branches with outpockets called alveoli that have outpockets called air cells. Clusters of air cells are called alveolar sacs. The alveolar walls form a membrane in which the transfer of gases occurs between the air passages and capillaries (31).

A surfactant material is synthesized and secreted in the alveolar wall. Macrophages involved in phagocytic action migrate up to the terminal bronchioles, where they become embedded in the mucous coating and pushed upward and outward. The phagocytic action, sticky mucus, detoxification substances, and lymphatic drainage help to filter and remove foreign matter from the respiratory tract (31).

The lungs and the tracheobronchial tree receive autonomic innervation. A variety of receptors send afferent impulses to the vagus nerve. Parasympathetic efferent impulses travel via the pulmonary plexuses and vagus nerve to the smooth muscles and glands causing muscle contraction, glandular secretion, and vasodilatation. Sympathetic efferent impulses pass from the sympathetic chain of the thoracic spine via the pulmonary plexuses to the lungs. This causes the opposite reaction compared with the parasympathetic supply, that is, smooth muscle relaxation, inhibition of glandular secretion, and vasoconstriction (31).

Goyal et al. (32) hypothesize that the parasympathetic system is a primary factor in the mechanism that leads to asthma. The parasympathetic system maintains tone in the airways via the vagus nerve. Vagal tone has been found to be higher than sympathetic tone in asthmatics (32).

In airway hyperresponsiveness, the cytokines, a subclass of helper cells, is thought to be involved. The exact mechanism does not seem to be established (33).

There is narrowing of the airways caused by bronchospasm, edema, inflammation of the bronchial mucosa, and the production of mucus (34). In response to localized hypoventilation, there is early hyperventilation. If the attack continues, there is further narrowing of the airways and fatigue of the musculature. This leads to arterial hypoxemia, increased pulmonary carbon dioxide levels, and respiratory acidosis, and can result in respiratory failure.

The neurologic origins of asthma have been thought to be related to trophic disturbances of the respiratory sympathetic neuromeres (T2-T7), which can cause sympathetic depletion or facilitation of respiratory parasympathetic neuromeres (vagus nerve to C1) (34). When caused by excessive parasympathetic effect, there is a disturbance in the cholinergic tone. Cholinergic tone is modulated by sympathetic adrenergic stimulation (anti-cholinergic effect) at the ganglion, in the airway, or both. Sympathetic neurotransmitters also inhibit secretions (immunological) by mast cells in the bronchial lining. Sympathetic stimulation (adrenergic effect) opens the airways and reduces edema and mucus secretion (35). In asthma, there is a hyperresponse to both cholinergic (parasympathetic) and alpha-adrenergic (sympathetic) neurotransmitters and a hyporesponse to beta-adrenergic (sympathetic) neurotransmitters (35).

Cytokines and chemokines are associated with inflammatory conditions. Tumor necrosis factor (TNF)-α, a pro-inflammatory cytokine, has been found in samples of sputum, bronchoalveolar lavage, and biopsies of asthmatics. TNF-α recruits neutrophils and eosinophils. Interferon-inducible protein 10 (IP-10) or chemokine ligand 10 is a Th1-related chemokine that has an important role in human allergic pulmonary reactions. Th2 lymphocyte infiltration into the airways has been found in asthmatics A Th2 chemokine, thymus and activation-regulated chemokine aids the recruitment of CC chemokine receptor 4-bearing Th2 cells, which occurs during allergen-challenged inflammation (36). All of these factors are associated with the airway inflammation of asthma. Obviously, asthma drugs are developed to address these factors.

Diet may be a factor in the progressive rise in the incidence of asthma, particularly in developed countries. Researchers are studying not only the diet of infants, but also the maternal prenatal diet as potential factors in the cause of asthma. Some suggest that the modern diet that is high in omega-6 polyunsaturated fatty acid (PUFA) and low in omega-3 PUFA increases the arachidonic acid levels in the inflammatory cell membrane and increases the production of prostaglandin (PG) E2 levels, which in turn suppresses T-helper cell differentiation and promotes Th2 phenotyping, and then increases IgE isotype switching and interleukin (IL) 4 and 5 production. These have been associated with asthma (37). Omega-3 fatty acid—in particular, eicosapentenoic acid and docosahexaenoic acid more than α-linolenic acid—has been found to have an antiinflammatory effect (38,39). Trans-fatty acid (transisomer of natural cis-linoleic acid) has also been implicated in increasing the risk of asthma. It is thought that the Western diet (high intake of processed meats, sugar, processed grains, oil-cooked foods, and hydrogenated fats) raises blood levels of inflammatory factors, such as, C-reactive protein, inflammatory cytokine IL-6, and vascular adhesion molecule E-selectin. They can create an environment for chronic inflammation (38). Dietary fiber has been found to have an inverse effect on C-reactive protein levels (38).

Vitamin D deficiency has been associated with many health problems, from infectious diseases to the classical deficiency disease, rickets. There is some controversy on the impact of maternal vitamin D levels on asthma in offspring. Gale et al. (40) found that high serum 25(OH)-vitamin D concentrations during late pregnancy are associated with increased risk of asthma and other atopic disorders in the child. There are problems with confounders and high follow-up loss with the Gale study (41). Other studies have found benefits for vitamin D, both for the mothers and the offspring. Wjst (42) found that additional maternal intake of vitamin D during the first and second trimester has been associated reduced risk of wheezing in their offsprings. Devereux (37) noted children with asthma whose mothers took vitamin D and E during the pregnancy. Low levels of serum vitamin D was associated with increase levels of IgE and eosinophils, which are markers for allergy. Infants in the United States have been found to have inadequate consumption of vitamin D. Breast milk has been found to be low in vitamin D. This is probably because many nursing mothers are not getting adequate vitamin D. Few infants get much sunlight, so that important avenue of vitamin D synthesis has been blocked. Low serum vitamin D levels have been associated with many disorders, from influenza to back pain. Recent studies have found that many children may have low serum vitamin D levels. Many children are slathered in sunscreen before they go outside, and many prefer television viewing, computer use, etc., primarily indoor activities, to outdoor activities.

Senaidy (43) found that serum vitamin A levels were lower in asthmatics than in controls. β-Carotene levels were checked in this study but were found to be similar among both asthmatics and controls. Another study found that high dietary levels of vitamin A are associated with a higher risk of asthma. This may be because of the immune system-enhancing effect of vitamin A, which increases the inflammatory response in the lungs. A study found vitamin E levels were similar among both controls and asthmatics (43).

Inadequate consumption of many minerals may be associated with asthma. Low dietary magnesium has been correlated with the incidence and progression of asthma (44), and increasing magnesium levels has been found to help with asthma (45). Oral magnesium supplementation has been found to reduce bronchial
responsiveness and increase peak expiratory flow rate (PEV). Magnesium’s effect is thought to be because of its interaction with calcium and its influence on the cell membrane, which may affect bronchodilation and antiinflammatory properties (44).

Some think that the high hygiene level of the most developed countries offers insufficient exposure of children to microbes. This, in turn, leads to aberrant intestinal flora. It is thought that supplementation through diet or probiotic supplements may have a positive effect on allergic disorders and asthma (46).

Physical exertion has been recognized as a cause of asthma or may aggravate an asthmatic condition. Up to 11% of world class athletes and 15% to 20% of the general population may be affected. Common symptoms include coughing, wheezing, chest tightness, and shortness of breath. This can occur during or after exercise. There are several theories on why exercise may induce asthmatic attacks. One theory is based upon the loss of water through the bronchial mucosa during exhalation, which may cause bronchospasm and change the environment of the airway epithelium. Another is that the transfer of heat from the pulmonary vascular beds and rewarming after exercise leads to dilation and hyperemia of the bronchiolar vessels (17,48). On the other hand, some studies have found moderate to vigorous exercise to be beneficial, particularly for overall fitness (49).

Various tools are used to assess/diagnosis asthma. Much of the diagnosis is based upon history and physical examination. Spirometry has been used. There are sometimes normal or false-negative testing with spirometry. Some have suggested the use of fractional exhaled nitric oxide. Findings have been mixed for fractional exhaled nitric oxide testing because of confounding by atopic conditions such as hay fever and atopic dermatitis (eczema) (50).

The treatment for asthma is to control it because there is no cure. Recently, the drug classifications have been simplified into two categories: quick relief and longterm control.

Typically, the bronchodilators used for quick relief are the short-acting β-adrenergic agonists such as albuterol, levalbuterol, and pirbuterol. Metaproterenol has been removed from the market. These are the drugs often delivered by metered inhalers. The pill or liquid forms are not recommended for children, have more side effects, and are slower acting than inhaler forms (4). At least among some populations, long-term use of β-adrenergic agonists, such as albuterol, leads to drug desensitization or tolerance (50). Short-acting β-adrenergic agonists have been known to cause exacerbation of asthma and asthma-related deaths over the past 50 years (51). There are some anti-cholinergic bronchodilators, but they are not approved by the U.S. Food and Drug Administration (FDA) as a quick relief drug (4).

Long-term control drugs come in several forms. One form, inhaled corticosteroids, has anti-inflammatory action. Inhaled long-acting β-agonist bronchodilators, such as salmeterol and formoterol, have been developed. It is said that they seem to be less effective over time and best used with anti-inflammatory medication. In the latter case, it might be associated with an increase in the risk of fatal or near-fatal asthmatic attacks. There have been serious discussions about the long-acting β-agonist drugs, in particular, salmeterol, before it was approved by the FDA for increased risk of asthma-related exacerbation and deaths. A manufacturer’s research trial of salmeterol found an asthmarelated death rate of 8 per 10,000 patients who were treated with salmeterol compared with placebo. In 2010 it was concluded that the benefits outweighed the risk with appropriate use. The United States developed in early 2010 new guidelines for salmeterol use. There are no studies that show that long-acting β-agonist drugs as monotherapy or in combination with inhaled corticosteroids increase survival or have a positive effect on severe asthma exacerbation (those that require intubation or hospital care) (51).

On a prophylactic basis, preschool children who are at high risk for asthma who have used an inhaledcorticosteroid (fluticasone propionate) for 2 years had no change in preventing the development of asthma symptoms or the development of lung function in the year after receiving treatment. Improvements during the treatment period disappeared when treatment ceased (52).

Inhaled corticosteroids seem to be the safest and most effective medical treatment for asthma attacks. In many asthmatics, inhaled corticosteroids suppress the inflammatory processes in the air passages and the synthesis of cytokines and other pro-inflammatory mediators, with the exception of leukotrienes. Some asthmatics have glucosteroid insensitivity and sometimes to other treatments as well (53). A study that compared the inhaled corticosteroids budesonide and fluticasone propionate found that budesonide improved the lung function more, but fluticasone propionate had a better anti-inflammatory effect (36).

Fluticasone propionate inhalant is being used as a replacement for inhaled corticosteroids among preschool children, although it is not approved for use in patients younger than the age of 4 years. Reports of
suppression of growth and of the adrenals have been reported at up to moderate doses. It has been associated with increases in body weight and body mass index (54).

The use of oral steroids is thought to be problematic. Wolkowitz et al. (55) report on a 10-year-old boy who was prescribed oral prednisone for mild but refractory asthma along with physical effects, he also developed memory and cognitive problems.

Stressors may cause imbalance in cytokine production and affect the hypothalamic-pituitary-adrenal axis, which affects cortisol production. It is thought that steroid use in asthma has a positive effect in this response, although it may have a negative effect on the adrenals in some individuals (56).

Leukotriene modifiers or cysteinyl leukotrienereceptor antagonists, such as montelukast, zafirlukast, and pranlukast, are another category of long-term control drugs. They decrease bronchial hyperresponsiveness and serum levels of various pro-inflammatory factors, such as cytokines. It is thought that they decrease leukotriene-producing inflammatory cells and thereby decrease leukotriene levels (53). One form has been found to cause reversible chemical hepatitis in some patients. A few cases of depression and suicidal ideation among children might be associated with montelukast.

Anti-IgE monoclonal antibody is being used in some cases. Anaphylaxis occurs in a few patients, approximately 1 to 2 per 1,000. Anti-IgE has not been approved for use in children younger than 12 months of age and it is a very expensive drug (4).

Medically, occasional asthma symptoms are treated with quick-acting bronchodilators. The next step up in severity or frequency is inhaled corticosteroids. In some milder cases, leukotriene-receptor antagonists might be used. If the above fail, the next recommendation is combined long-acting β-agonist and inhaled corticosteroid (4).

There are several studies in the chiropractic literature on the effects of chiropractic care for those suffering from asthma. The osteopathic literature implicates lesions in the midthoracic spine, which cause a neurogenic reflex. Many chiropractors have seen asthmatic episodes abate after adjustments to the cervical or thoracic spine.

Vernon and Vernon (57) note that spinal adjustments may benefit asthma sufferers because of the effect that adjustments/manipulation seem to have on the autonomic nervous system. In the field of neuroimmunomodulation, dysfunction in the musculoskeletal system may have an adverse effect on the immune system. They suggest a study comparing patients receiving chiropractic adjustments with those receiving drug therapy using peak flow meter and pulse oximeter measurements (57).

Arbiloff (58) presented a case of a 7-year-old white boy who was experiencing acute asthma. Ten months earlier he had an initial attack, which was treated with bronchodilators and bed rest. Over the next several months, he had increasingly frequent and severe attacks. During the summer, attacks subsided but resumed in the fall. As an infant he had poor sleeping and eating habits. He had croup for 5 years from the age of 18 months. In a laboratory work-up, blood values were within normal limits except an elevated eosinophil count, but Curschmann’s spirals were found in the sputum. Chest x-rays were unremarkable. Adjustments were made in the upper thoracic spine using a posterior to anterior Meric double transverse thrust and rotatory adjustments to the cervical spine. Nutritional supplements were given as well. The difficulty breathing and the wheezing ceased within 2 minutes of the adjustment and was followed by coughing with a large amount of thick, stringy, mucoid sputum being expectorated. He was adjusted three times a week for 4 months, during which time he had two brief attacks; twice a week for 6 months, during which he had six moderate intensity attacks; and once weekly for 10 months, during which he had three attacks (two during an upper respiratory infection and one after exposure to paint fumes) (58).

Mega (59) gives two brief stories about asthmatics benefiting from chiropractic care in his article on the possible mechanism involved in asthma, particularly the neurological aspect. His introduction to chiropractic was his personal story of having asthma that did not respond to allopathic medical care. A chiropractor began adjusting him and encouraged him to change his diet. He was free of attacks until World War II. During the war, he began smoking and eating poorly and the asthma attacks resumed. After giving up smoking and changing his diet (he could not get adjusted), the attacks ceased. He mentions that he helped a medical doctor’s son who had asthma.

In another article, Mega (60) states that it is beneficial for asthma sufferers to remove toxic internal conditions. He states that asthmatics suffer from gastrointestinal tract and liver dysfunction and, in many cases, pancreas dysfunction. He recommends removing acid-producing foods, such as meat, eggs, and dairy products, and replacing them with vegetables and fruits. In some cases, the patient is put on a 3-day orange or grapefruit juice fast or 2 days on distilled water. Adjustments are first given to the sacroiliac joints, and then the lumbars, upper thoracic spine, and occiput. Breathing exercises are also given.

Jameson et al. (61) did a pilot study on the effects of chiropractic care on asthma. The measurements
used included patient perception, forced vital capacity (FVC), forced expiratory volume in one second (FEV₁), and maximum voluntary ventilation. Measurements were taken immediately before the care was rendered and within 5 minutes after care. Clinicians were two senior students and 15 patients aged 9 to 36 years participated. Most of the patients were 28 years of age or older. Four were younger than 12 years old. Most had mild to moderate cases of asthma. Seven treatments were given over a 5-week period. The care rendered included spinal adjustments, soft tissue work, mobilization, and home exercises. The study listed neither the levels of the spine adjusted nor the type of adjustments given. Subjects were requested not to use bronchodilators during the 4 hours prior to receiving care. The trial was performed during an asthma “high risk” season. Subjectively, the subjects were satisfied with the care they received. One subject stopped taking medication and six others reduced their medication. The objective tests showed little overall change (61).

Nilsson and Christiansen (62) did a retrospective study of 100 consecutive patients with asthma from a private chiropractic practice. Seventy-nine had sufficient information to be included. Not all were children; the age range was 2 to 63 years old. The number of chiropractic treatments ranged from one to nine over an average period of 1 month. Those with the best improvement were the youngest patients. Those using the least amount of drugs, who were considered to be the least severe cases, responded the best.

Cohen (63) described a case of an 8-year-old girl suffering from severe asthma since age 2. The child was delivered in a breech presentation. She was a passenger in two automobile accidents, which occurred when she was 6 and 7 years of age. The mother smoked during the pregnancy but supposedly ceased, and the father still smoked but not in the presence of the child. The child was hospitalized regularly for asthma attacks and usually missed at least one day of school a week. As might be expected, the family was under significant stress because of the severity of her condition. She was prescribed Slobid, Alupent, and Ramtidine and also used three inhalants (Intal, Ventolin, and Azmacort). All medications were taken daily. She had previously been prescribed prednisone and took Tylenol regularly for other complaints. The chiropractic evaluation found a short right leg, positive Derifield test, thoracolumbar scoliosis, and vertebral subluxation complexes in the upper cervical spine. She was examined three times a week for a month and, if indicated, was adjusted. This was later reduced to twice weekly. The parents altered her diet by removing sugar, refined foods, and preservativeladen foods. During the course of care, the pediatrician reduced her medication. At the time the report was written, the child no longer required drugs and for the past month had not missed a day in school. It was reported that she had “steady improvement” (63).

Garde (64) presented a case of a 5-year-old boy with a history of respiratory problems. He was diagnosed with asthma and prescribed Beclovent and Ventolin inhalants, which he used daily. Upon presentation for a chiropractic evaluation, his complaints included activity-induced neck pain and stiffness, nasal passages closed by mucous, and an abnormal breathing pattern without diaphragmatic breathing. Based on the history, examination, and x-ray findings, chiropractic care was commenced. Over a 12-month period of time, adjustments were made to the cervical, thoracic, and lumbar spine. Postural and breathing exercises were given. During the first 6 months of care, there were reductions in musculoskeletal abnormalities, his activities increased, use of the inhalers decreased, breathing improved, and mucous rarely blocked his nasal passageways. After a year of care, he ceased using the inhalers and did not have a recurrence of respiratory problems.

A study by Wiles and Diakow (34) was based on interviews of 241 chiropractors on how they care for asthmatic patients. More than 94% adjusted the patient. Other commonly used modalities included nutrition, soft tissue manipulation, exercise, psychotherapy, and electrotherapy. The primary area adjusted (almost 59%) was the T1-T6 region. This was followed, in descending order, by the upper cervical spine (occiput to axis), lower thoracic spine (T7-T12), lower cervical spine (C3-C7), ribs, lumbars, and sacroiliac joints. The most common nutritional supplements were vitamins C and A. General dietary advice and avoidance of dietary triggers were made in many cases (34).

Bachman and Lantz (65) describe a case of a nearly 3-year-old boy with asthma and enuresis with a traumatic etiology. Metaproterenol syrup and Theodore Sprinkle were prescribed to control the asthma. A year later, an initial chiropractic work-up was done and chiropractic care was initiated. Over a 2½-month period, 28 chiropractic adjustments were given using the Gonstead System protocols. T3, T12, and the second sacral segment were adjusted. After 2 weeks of care, asthmatic symptoms ceased. Two months later, asthma symptoms recurred along with nightly enuresis after a minor fall. Both symptoms ceased after three visits. A year later, the boy fell off of a horse and both symptoms reappeared. Chiropractic care was administered several months later, and again symptoms ceased. More than a year later, the child was evaluated, and no further symptomatic episodes since the last visit was noted. After beginning chiropractic care, asthma drugs were only used as needed.

Peet et al. (66) did a 9-month study with 12 patients between the ages of 4 and 12 years. Of these, eight completed the trial. Each patient had a medical diagnosis
of asthma and was taking at least two drugs for the condition. Each was x-rayed and evaluated posturally with a Metrecom three-dimensional postural computer system. All had abnormal findings. A peak flow meter was used to test lung capacity before the first adjustment and before and after subsequent adjustments. Mirror-image maneuvers were also given to each patient per the procedures of Chiropractic Biophysics technique. During the course of care, seven of the eight who completed the study were able to reduce or discontinue the use of drugs; lung capacity as measured with a peak flow meter increased, although some decrease was noted after the 10th visit, which was thought to be attributed to a rebound effect with decreased use of drugs. X-rays taken at the 15th visit showed an improvement in spinal alignment. At the end of the study, seven of the eight parents felt that chiropractic care reduced their child’s need for asthma drugs. Four found that their children did not require drugs, and two found that their children did not required inhalers (66).

Burnier (67) gives a brief mention of an 11-year-old male athlete with asthma who had been on Theolair and Alupent for the condition. A subluxation was determined to be at the C1 level. An adjustment was made at C1. After the first visit, the patient ceased taking medication. Six years after beginning chiropractic care, he had not had asthma nor required medication. A 9-year-old boy also was mentioned. He suffered from chronic asthma and was taking NasalCrom. After the first adjustment to the C1 vertebra, medication was not required and the patient had remained free of asthma at the time the article was written. Both reports were very brief with little information except that noted above.

Killinger (68) described a 1949 case from the files of the B.J. Palmer Chiropractic Clinic. An 18-year-old man had been diagnosed with asthma 2 years before seeking chiropractic care. Attacks occurred daily, typically at night or in the early morning. The attacks began around the time that his neck was stepped on during a football game. Before that injury, he had a serious fall from a horse and had neck pain for several years. C1 was found to be misaligned and was adjusted using the Palmer Upper Cervical Specific, or toggle-recoil, technique. He received two adjustments during the first 2 weeks of care. Breathing improved and the severity and duration of attacks decreased. Over a 5-year period, he received care once a year and asthma symptoms had largely abated.

Case studies by Lines (69) showed benefits from chiropractic adjustments along with avoidance of substances that seemed to trigger asthmatic attacks. The patient or parent was instructed to keep a diary of foods and drinks ingested in the 4 hours before attacks for a 7-day period. If foods and drinks did not seem to be the sole precipitators, exposure to other factors such as drugs, tobacco smoke, and physical activities were noted. Two of the three cases described were of children, 5-year-old and 2-year-old girls. Both had required hospitalization for the most severe attacks and took medication during attacks. Both were found to have eaten foods that appeared to trigger the attacks. Common factors seemed to be milk, artificial colors, monosodium glutamate, and sulfur-based preservatives. These two children were adjusted and the offending foods were removed. During follow-ups at 20 months and later, neither child had further attacks. Lines (69) found that, after a period of time, the triggering substances did not have as significant an effect on the patient.

Hayek et al. (70) presented a trial of 420 asthma patients at 16 Australian centers; the patients’ average age was 46 years old. The measures for change were symptoms, depression, anxiety, general health status, IgA levels, and cortisol (an immunosuppressant) levels. Only the patients who received spinal adjustments showed any significant improvements in asthma symptoms, depression, and anxiety scores. This group of patients had significant increases in IgA levels and decreases in cortisol levels.

A 6-year-old girl was taken in for chiropractic assessment by her mother. At the age of 4 months she was seen by a medical doctor, at which time she had dark circles under her eyes, a dry cough, and a low-grade fever. A diagnosis of bronchitis was made and antibiotics were given. At age 2 years she was diagnosed with walking pneumonia and given antibiotics and Proventil, the latter to be used as needed. The Proventil was given for a couple of years. At age 4 years, she developed a severe cough and a medical doctor was consulted. The diagnosis was an asthma attack. She received treatments of saline and water mist. AeroBid/flunisolide and Proventil/albuterol inhalers were prescribed and to be used three times a day. After a time, the mother noted that the child became upset if she was not given the inhaler, and the mother was worried about drug dependency. Another doctor took her off of the AeroBid inhaler. The child presented to the chiropractic office. Diversified adjustments were given in the thoracic spine and ultrasound was also administered. She was seen weekly for 3 weeks. At the end of 3 weeks, she was able to play longer without resorting to an inhaler. After another 3 weeks, she did not complain of breathing problems during gym class. During the next 3 weeks, she had gone for a week without using the inhaler. A couple of months later, she had only used the inhaler once. During a subsequent medical examination, the mother told the medical doctor that her daughter has begun experiencing a normal and active lifestyle and did not want her on the prescribed drugs (71).

Postles et al. (72) wrote up a case of a 4-year-old who presented with asthma, bed-wetting, and snoring.
Asthma symptoms began during the teething phase. The medical doctor prescribed two inhalers, one with corticosteroid and a bronchodilator and the other with a β₂-andrenergic receptor agonist. After 2 weeks the mother decided to seek another form of care because the same medication was given to the boy’s older sister, who continued to suffer from asthma and other respiratory issues. Chiropractic care consisted of Sacro-Occipital Technique (SOT) protocols. Vertebral subluxations at T3, T7, and T9 were adjusted using an activator instrument and the pelvis received SOT blocking at intervals during the first 8 weeks of twicea-week visits and at weekly intervals for 24 weeks. Asthma symptoms ceased after 2 weeks of care. Snoring stopped immediately after care was initiated and bedwetting ceased after 6 weeks of care. Two months after the initiation of care, the child had two incidences of symptomatic asthma that occurred after the child hit his head. On both occasion, the β₂-andrenergic receptor agonist was used in the evening and the child received chiropractic care the next day. Symptoms ceased after the interventions. After 32 weeks of care, the use of inhalers was sporadic.

A 7-year-old girl presented to a chiropractic office with uncontrolled asthma of 4 years standing in spite of using several medications. Initially, she was using three inhalers, four times a day. She was taking 10 medications for fever and cough. Five times a year, the asthma was severe enough to warrant trips to the emergency room. Her condition continued to worsen. Before presenting for chiropractic care, her PEV was 95 L/min (174 L/min is normal). Chiropractic care was Chiropractic Biophysics mirror image technique and, when found, adjustments to T2 and T12. For the first 3 weeks, care was rendered two to three times a week. The coughing ceased after the first adjustment, and she did not have asthma attacks by the end of 3 weeks of care. Her level of activity increased without an increase in symptoms as had happened the past. After 10 months of chiropractic care, she did not require medication. After 3 months of care, her PEV went up to 165 L/min. Her FVC and FEV₁ showed improvement with medication, which continued under chiropractic care and was maintained after she stopped using the medication (73).

Cuthbert (74) discussed 10 asthmatic patients from ages 3 years to 33 years. Using protocols of applied kinesiology, in nine out of 10 patients, diaphragmatic weakness was found. In all cases, dysfunction was found at the C3-C5 levels. The C3 to C5 area was adjusted in each case. Various other musculoskeletal dysfunctions were found on the patients, such as in the ribs and upper and lower thoracic spine. In eight of the patients, signs of adrenal stress were found: postural hypotension (Ragland’s sign), paradoxical pupillary reaction, and Rogoff’s sign. Reduction in asthma and respiratory symptoms occurred with chiropractic care. All were able to stop taking asthma medication after three to six visits, which occurred over a period of 2 weeks to 5 months. At follow-up 3 months to 4 years later, none had a return of asthma symptoms or required asthma medication.

Worrill (75) describes a 33-year-old woman who had suffered from asthma since the age of 5 years. It became worse after the birth of her child 2 years before presentation to the office. Six months before seeking chiropractic care, she had an asthma attack and was on oral steroids for 4 days. Otherwise, she was receiving Ventolin/salbutamol, a β-agonist, and Becotide/beclomethasone dipropionate. After the birth of her child, she needed to use an inhaler four to five times a day, which only partially controlled symptoms. She presented with wheezing, shortness of breath, a feeling that she could not fully expand her chest, upper and lower thoracic spine pain, and neck pain and stiffness. Intersegmental restriction was found at C1-3, T3-6, and T7-8 with tenderness to palpation at those levels. During the first week of care, adjustments were given on three visits to the upper cervical and thoracic spine. She reported fewer symptoms and the reduction in the use of the inhaler. The next 2 weeks she was seen twice a week. Symptoms continued to improve, and she only used the inhaler once at night. Chiropractic care continued and no severe asthmatic episodes occurred.

A 43-year-old woman presented to a chiropractic office complaining of mid-thoracic pain and stiffness of 2 years standing that had recently gotten worse. She also had a history of asthma that was diagnosed at age 38 and had been using becotide (beclometasone dipropinonate) daily and Ventolin (salbutamol) when needed. She had a history of recurrent chest infections since childhood. The asthma was aggravated by foggy damp weather and by exercise. The latter inhibited her job as a part-time aerobic instructor. The examination found a loss of the thoracic curve with discomfort during thoracic flexion, extension, and bilateral lateral flexion at end-range. Segmental range of motion was restricted in the lower cervical and upper thoracic spine and the costovertebral junctions from T2-T5. Hypertonic musculature was noted in the upper thoracic, cervical, and interscapular areas. Spirometry testing showed a PEV of 430 L/min, lower than the normal of 500 L/min or more. The patient received adjustments to the cervical and upper thoracic spine and costovertebral joints. The hypertonic muscles also were addressed with trigger point, massage, and relaxation techniques as well as home exercises. After the first visit, the thoracic pain and asthma symptoms improved. Over a 12-month period, the PEV went from 430 to 550 L/min. Her dosage of Becotide was reduced 50% in 1 month and ceased in 3 months. Ventolin was used occasionally (5).

A case series by Gibbs (76) presented three patients with asthma who received chiropractic care. Each patient received high-velocity, low-amplitude diversified adjustments of the upper thoracic spine. Patient 1 was a 28-year-old man who had asthma since childhood. He used a Becotide inhaler in the morning and night and a Ventolin inhaler when needed. After 6 weeks of chiropractic care, his PEV had improved and Ventolin used decreased (used nightly at the initiation of care). After a few weeks of care, he forgot to use the Ventolin inhaler one night and had a “great night’s sleep.” He did not use the Ventolin at night after that. He continued with maintenance care. The second was a 56-year-old woman who had been diagnosed 5 years previously with asthma. She presented with tightness in the chest and coughing. After 2 weeks of chiropractic care, she was able to breath easier with less coughing and felt “much better within herself.” Secondarily, she felt less tired and her dry skin condition improved dramatically. She continued chiropractic care. Patient 3 was a 26-year-old woman who had asthma since childhood. She was a competitive rugby player who required the use of Ventolin inhalers multiple times during games. She also woke up once a night with wheezing and used an inhaler. At the end of the chiropractic trial, she was able to play an entire game of rugby without the use of the inhaler and was able to sleep the entire night. Beyeler (77) and Hvlid (78) also wrote about the benefits of chiropractic care on asthma and respiratory function.

Alcantara et al. (79) wrote up a case of a 7-year-old boy who suffered from chronic colds, allergies, and asthma since the age of 5 months. He was receiving once-a-day doses of Alavert for allergies and Albuterol was used “as needed” for asthma. He also suffered from episodes of tonsillitis and bronchitis. Birth was by cesarean section. Chiropractic examination found postural findings of head tilt and restrictions in cervical and thoracolumbar motion. Hypertonic and tender muscles were found in the spine. Adjustments were often given to C1, T6, and L5. During the first 3 weeks of thriceweekly care, the mother stated that allergy medications were not needed. Asthma attacks were less frequent and less severe and inhaler treatments were not needed. After 2 months of care, the patient had sinusitis, which resolved quickly. On a check-up after 16 months, he had only needed the asthma inhaler twice.

An asthma trial of osteopathic manipulative therapy (OMT) was done. The physiological changes that the authors hoped for when using OMT for asthma include the following: (a) maximize thoracic cage compliance to increase respiratory motion; (b) normalize the autonomic nervous system function; and (c) facilitate lymph flow to and from the bronchial tree. In this case, the 10 female patients had chronic asthma and were over the age of 18 years. The patients received two series of treatments: OMT was administered to the atlantooccipital and cervico-thoracic regions, and patients received Still’s rib and diaphragmatic releases and sham treatments. Some received OMT first, others received sham first. Thoracic excursion measurement changes were slight. Some symptomatic changes were noted after OMT compared with sham, but they were not statistically significant. One problem that the authors noted was that they did the same procedure on each subject rather than individualize or customize the care to their findings on each patient (80).

Many of the larger studies find that chiropractic care helps the asthmatic patient subjectively but not necessarily objectively. Subjective improvement helps quality of life and the sense of comfort and security. That is an improvement over the usual medical care for asthma, which, not uncommonly, goes from one crisis to another.

If chiropractors wish to do outcome studies (objective case reports) on the efficacy of chiropractic spinal adjustments for bronchial asthma, they should follow accepted protocols. FEV₁ and vital capacity are measured. Peak expiratory flow rate (PEFR) has also been used, although FEV₁ is thought to be a better tool. Other outcome measures that probably will be used more frequently in asthma studies are quality-of-life questionnaires. Quality-of-life studies are a fast growing area for studying the efficacy of different treatments in this era of managed care. There are many types of quality-of-life questionnaires used for asthma, but most are better suited to adults. For children, there are the Childhood Asthma Questionnaire, Children’s Asthma Symptom Checklist, and the Life Activities Questionnaire for Childhood Asthma (81). Clinical markers for airway inflammatory response include exhaled nitric oxide concentrations and sputum eosinophilia. Bronchial hyperresponsiveness is also tested (4).

The signs and symptoms commonly associated with diabetes include the following (97):

1. Excess thirst

2. Excess urination

3. Excess hunger

4. Fatigue

5. Losing weight without effort

6. Sores that heal slowly

7. Dry, itchy skin

8. Loss of feeling or tingling in hands and/or feet

9. Blurry vision

The American Diabetes Association has a list of possible signs for the diagnosis of diabetes (83):

1. Symptoms of hyperglycemia (e.g., polyuria, polydipsia, and unexplained weight loss) and random plasma glucose concentrations of >200 mg/dL.

2. Plasma glucose level >126 mg/dL after 8 hours or more with no caloric intake.

3. Two-hour plasma glucose of >200 mg/dL during an oral glucose tolerance test, performed in the manner described by the World Health Organization that uses a glucose load that contains the equivalent of 75 anhydrous glucose dissolved in water. This test is repeated in asymptomatic patients to obtain a reliable diagnosis.

4. A HbA_tc test that is performed in a NGSP-certified laboratory of ≥6.5%. A second sample is required in asymptomatic patients to confirm the first result. This test is controversial.

The American Diabetes Association recommends testing for prediabetes (83):

1. Impairment of fasting glucose with plasma glucose levels of 100 to 125 mg/dL.

2. Impairment of glucose tolerance with 2-hour plasma glucose levels of 140 to 199 mg/dL during an oral glucose tolerance test.

3. Check for HbA_tc via a NGSP-certified laboratory of 5.7% to 6.4%.

Differential diagnosis of type 1 and 2 diabetes among the pediatric population is difficult. In type 2 diabetes, negative β-cell antibodies have been found. Insulin and C-peptide levels are usually high in type 2 diabetes because they may indicate insulin resistance. However, these are not always diagnostic for type 2 diabetes because there is overlap in both types. Those with type 2 diabetes may have acanthosis nigricans, which is indicative of insulin resistance. It is characterized by skin that is velvety, hyperpigmented, and thickened (83). Type 2 diabetics may also show metabolic changes that include hypertension, microalbuminuria, dyslipidemia, and steatohepatitis (83).

Consensus guidelines were developed in 2006 and 2007. The great concern is to prevent hypoglycemia, particularly severe episodes of it. Another major complication is diabetic ketoacidosis. The primary treatment is insulin. Children with type 1 diabetes often require twicedaily injections of insulin. Some require interim doses of fast-acting insulin. The insulin pump is another means of delivering insulin. It is thought to better replicate the natural release of insulin.

Insulin comes in a variety of forms. Regular, shortacting insulin is identical to human insulin and is commonly used around the world. It is the best form used intravenously, particularly for diabetic ketoacidosis crises and to control diabetes during surgery. Rapid-acting insulin analogues are quicker acting but of shorter duration than regular insulin. There are currently three types for children: lispro, aspart, and glulisine. They can be given immediately after meals to counteract hyperglycemia that may occur after eating. They are also given for nocturnal hyperglycemia, especially when combined with longer-acting insulin in basal bolus regimens.

The rapid-acting insulin analogues are often used in insulin pumps and can be given intravenously. The latter form of delivery is less effective than it is with regular insulin (98). Insulin pumps or continuous subcutaneous insulin infusion (CSII) is being tested for safety, effectiveness, and compliance among the pediatric type 1 diabetic patient in several countries (85). In children younger than 6, insulin pumps seem to offer better metabolic control and decrease the risk of severe hypoglycemia compared with multiple daily subcutaneous injections. The children in one study seemed to prefer CSII to multiple daily subcutaneous injections. CSII seems to be a viable first line of defense rather than the last, as in the past (99).

Intermediate-acting insulin is best for two daily dose and the nocturnal basal bolus regimens. They come in two forms: isophane NPH and crystalline zinc acetate. The isophane form of insulin is often used in combination with regular insulin for children, although zinc in the preparation slows the action of regular insulin.

The basal insulin analogues are glargine and detemir. They are more predictable than isophane NPH insulins and seem to be effective in children from age 1 to 5 years,
although their use in this age group has not been approved in many countries. Glargine has been found to be effective for nearly 24 hours. The acidic nature of glargine has brought reports of a burning sensation in some children. Detemir seems to have an effect of slowing weight gain or reducing weight in both children and adolescents and in adults. An inhaled form of insulin is being investigated at this time. Its clinical use in children has not been approved (98).

Some people do encounter problems at the injection sites. Some people have hypersensitivity that is usually because of the type of insulin given or, on rare occasions, because of the preservative used. Lipohypertrophy (lumpy fatty accumulations) and lipoatrophy have been described. The latter is less common with more purified insulin preparations and analogue insulin. Other problems are painful injections (particularly when given intramuscularly or when using blunt needles), leakage of insulin upon withdrawal of the needle, bruising and bleeding at the injection site, and bubbles in the insulin (98).

Children with type 2 diabetes, especially youths who are obese, who present with diabetic ketoacidosis require subcutaneous or intravenous insulin. Asymptomatic youth who have obesity, poor nutrition, and a sedentary lifestyle need to address these issues. These issues are often challenging to change because the children often come from households where these lifestyle features are the norm. The difficulty of improving their lifestyle often requires drug intervention (83).

Metformin is the only oral antidiabetic drug that has been approved for the treatment of type 2 diabetes among the pediatric population. Exenatide has been approved for use in adult type 2 diabetes, but only a preliminary study has been done in adolescents (83).

There are few cases of chiropractic management of diabetes mellitus. Management of both potentially related and unrelated neuromusculoskeletal disorders for these patients is a valuable service that chiropractors can provide. Many do have neuromusculoskeletal sequelae of diabetes.

Nelson (100) presented two cases of middle-aged individuals with diabetes mellitus who presented with symptoms that resisted other care. Patient 1 was a 38-year-old woman who was diagnosed with diabetes at 4 years of age. She complained of nervousness, much of which was over the nature and future of juvenile diabetes (shorter life expectancy), and prolonged menstrual cycles. The author used the protocols of the neurovascular dynamics technique, which seems to be a soft tissue technique. Through this procedure, the menstrual problems and the nervousness resolved. She continued care usually if her vitality was low or she had symptoms such as lower back pain or neck stiffness. At age 38 when care began, she was taking 18 units of insulin daily. At age 50, she was taking 14 units daily. Although she was anxious, her health and vision remained well.

The second case presented by Nelson (100) was a 61-year-old man who had developed diabetes at age 47. He was taking an oral glucose-lowering drug. He began having circulatory problems in the lower extremities that persisted despite changes in medications. Palpation found coolness from the midcalf to the soles of the feet. From midcalf, cephalically, the legs felt warm. This patient also received neurovascular dynamic treatments. After 5 months of twice-weekly treatments, the legs were warm down to the ankles. Care continued once weekly for another 5 months, and the warmth continued to the soles. Nelson opines that stress appeared to affect vasomotor balance (100). Although the technique is lighttouch, chiropractic care may have an impact on musculoskeletal and possibly other manifestations of diabetes mellitus.

Although anecdotal, some chiropractors have been able to help some diabetics, particularly borderline or new cases. The author recalls a heavy-set Latina who came in for care with mid-back pain. She stated that she had been recently diagnosed with borderline type 2 diabetes and had begun daily insulin injections. After a short course of adjustments for a T-9 subluxation, she informed the author that her medical doctor told her that her blood glucose level was within normal limits, and she was able to cease the insulin injections, which had given her considerable anxiety of a future of daily injections.

Dietary control is vital. The basic diet should be balanced with enough calories and nutrients. One recommended is 50% to 55% carbohydrate, 20% protein, and 39% fats. Exercise is an important part of the regimen. Food intake with exercise should be monitored to prevent post-exercise hypoglycemia (86).

Breast-feeding seems to reduce the risk of type 1 diabetes, and not breast-feeding increased the risk. Longer term breast-feeding lowered the risk (101).

Prospective cohort studies have found the first signs of β-cell autoimmunity may begin in the first year of life. The dietary regimen sets the stage for risk factors for β-cell autoimmunity and type 1 diabetes in the infant’s future life. Early introduction of cow’s milk seems to be a risk factor for type 1 diabetes, as are both glutencontaining and non-gluten-containing cereals (94). The latter would be a high glycemic index food, which will be discussed below. Using cod liver oil during the first
year of life was related to a lower risk of type 1 diabetes because it contains high levels of vitamin D and omega-3 PUFAs (94).

Controlling the ingestion of food and drinks with a high glycemic index is important, and those who carefully control their glucose levels through diet are well aware of it. A 2004 study found that prevalence of type 2 diabetes in the United States has increased alongside increases in consumption of refined carbohydrates, largely in the form of corn syrup, and a decrease in the consumption of dietary fiber is largely because of the prevalence in the diet of refined flour (84). Some people are telling diabetics that they can consume fructose because it has a low glycemic index. Unlike glucose, which is processed in the gut lining, fructose is processed in the liver and does not require insulin. It is converted to triose-phosphates, which are fatty acid precursors and cause both lipogenesis and lipid oxidation (102). Fructose, refined from agave (also known as chicory syrup) and corn syrup, among other sources, seems to be more tolerable, but it does put extra stress on the liver, particularly if a considerable amount is ingested daily. When processed by the body, it circulates as triglycerides. Because it does not stimulate insulin or affect leptin levels, the body has difficulty regulating appetite and satiety. Fructose is known to affect insulin sensitivity in the liver (102). It can also cause a loss of nutrients in the body because it does not contain any. It may actually have a role in causing diabetic complications via the Maillard reaction, which causes the browning and alteration of foods in the presence of sugars (103), and sugar and amino acid reaction either with storage or heat (104). Many have switched from soft drinks to fruit juices because the latter are thought to be healthier, but many fruit drinks are sweetened. A study of African-American women found a similar incidence of type 2 diabetes among those who drank soft drinks or sweetened fruit drinks. This study did not find an association of diabetes risk and orange and grapefruit juices and diet soft drinks (105).

High-temperature cooking was found to cause markers associated with type 2 diabetes compared with a diet with predominately mild steam cooking. This is also because of the Maillard reaction. There was a higher percentage of Maillard reaction products with foods prepared at high temperatures compared with the mild steamed foods, but lower vitamin C and docosahexaenoic acid (omega-3) in the plasma. With the high-temperature food diet, insulin was not as efficient at normalizing blood glucose levels. Not only the fat content, but also the high heating of foods, such as hamburger patties and French fries as well as processed food such as cookies, cereals, and other snacks, has negative effects on health and may also lead to type 2 diabetes (104).

The 1972 Framingham Offspring Study was the database used for a regression model on vitamin D (25[OH]D) and type 2 diabetes. The conclusion was that higher levels of plasma 25(OH)D inversely correlated with the incidence of type 2 diabetes (106). Serum vitamin D levels that are sufficiently high enough have been found to reduce the risk of both type 1 and 2 diabetes (94,106,107). It seems to have an unknown but positive influence on pancreatic β-cell function and insulin resistance. It might be because of its effect on parathyroid function. When serum vitamin D levels are low, parathyroid hormone concentrations are higher. The high hormone levels inhibit the synthesis of insulin and secretions from beta cells. Sunlight via ultraviolet B converts 7-dehydrocholesterol to 25-hydroxyvitamin D (106,107). Other sources are oily fish, mushrooms dried in the sun gills up and eaten quickly, fortified foods and beverages, and nutritional supplements of vitamin D. A study by Biancuzzo et al. (108) found that fortified orange juice and supplement sources have equal bioavailability. Slathering on sunscreen is a commendable safety procedure to protect children from potential skin cancer, but it does have a negative effect on the synthesis of vitamin D and other required processes that require skin exposure.

A study found that a high serum vitamin C level has been found to reduce the risk of diabetes. It found that both men and women in the lower quintile of serum vitamin C levels had a 62% higher risk of developing diabetes than those in the highest quintile. It found that a diet high in fruits and vegetables had some effect on lowering the risk of diabetes, but the correlation was much lower than for the serum vitamin C level (109). Those who were physically active were found to have high plasma vitamin C levels (110). Vitamin E also may have a protective effect against diabetes (94). More studies need to be conducted.

The spice cinnamon has been found to be beneficial to those with type 2 diabetes. One study found that cinnamon, which has chromium and polyphenols, reduced mean fasting serum glucose level as well as serum cholesterol levels (111). Another diabetes study has observed that cinnamon benefited diabetic patients by reducing insulin resistance, glucose and lipids, the inflammatory process, weight gain, and glycation of proteins and increased antioxidant activity. This benefits blood pressure, lean body mass, and gastric emptying (112). A meta-analysis of various studies on the effects of cinnamon found evidence that cinnamon reduced serum glucose levels in two of three studies. This study also noted that chromium reduced serum glucose levels as well as glycosylated hemoglobin levels (113).

Green tea has been found to have numerous health benefits. In one of three studies, serum glucose levels were reduced. The effects are thought to be caused by
polyphenol catechins, which improve insulin sensitivity and reduce β-cell damage (113). Caffeine has an initial effect of impairing insulin sensitivity, but long-term consumption stimulates lipolysis, increases basal energy expenditure, and mobilizes muscle glycogen (113).

The ayurvedic medicine, Gymnema sylvestre, or gurmar, has been used to treat diabetes. Its active ingredient is thought to be gymnemic acid, which is composed of various saponins. Small studies showed that it improved serum glucose and chromium-reduced glycosylated hemoglobin levels (113).

Another key lifestyle intervention, particularly for type 2 diabetes, is physical activity. It may improve glycemic control and reduce the risk of both microvascular and macrovascular complications. It may increase insulin sensitivity, reduce stress and depression, help reduce weight, and help control lipids and blood pressure. The latter will reduce the risk of cardiovascular disease, a leading cause of death among diabetic patients (88). One also needs to be aware of stress level because this will affect serum glucose levels. Physical activity can reduce obesity. As mentioned previously, obesity is a risk factor for diabetes. One study found that those who exercised at least 1 hour per week reduced their consumption of sugar-sweetened soda beverages (110).

Typically, the parents are reassured that they are handling the child correctly and that the condition usually ceases shortly. Holding, rocking, or patting the infant may help. If the infant feeds quickly, a smaller nipple on the bottle should be tried. A pacifier or feeding in the upright position may help (117,128). A quiet environment or music or placing the infant in a warm bath and gently massaging the abdomen may be beneficial as well (120).

In a study by Colon (115), 30% of colicky infants from whom cow’s milk was removed had a cessation of colic. Formula-fed infants have not been found to be more prone to colic than breast-fed infants (118).

In some cases, the colicky infant is given drugs. Some have been given a combination of dimenhydrinate (trade name Dramamine) and Donnatal (a combination of phenobarbital, hyoscyamine sulfate, atropine sulfate, scopolamine hydrobromide, and alcohol). These drugs contain anticholinergic and antimuscarinic agents, smooth muscle relaxants, and central nervous system (CNS) depressants. Alcohol reduces lower esophageal sphincter tone, which is associated with gastroesophageal reflux. These drugs seem to have caused instances of apparent life-threatening events (ALTE) in a few infants with cardiorespiratory control abnormalities or who were otherwise at risk. The ALTE or apnea of infancy were characterized by choking, apnea, and cyanosis. In a study of eight infants younger than 14 weeks of age receiving the Dramamine/Donnatal combination for colic at the time of their ALTE, five were sleeping at the time of the episode whereas the remaining three were awake or feeding. Four required cardiopulmonary resuscitation, and the other half responded to stimulation (129).

Some colicky infants are given simethicone or methylpolysiloxane. It is used to treat the increased gastrointestinal gas that is thought be a factor in colic through its effect of altering the surface tension of gas bubbles. Simethicone is not absorbed by the gastrointestinal tract. It also has not been demonstrated to be helpful. In most trials, it has not been any more effective than placebo (128). Dicyclomine also has been used but has been contraindicated because of the risk of apnea in children (124).

One review study found that among many colic treatment studies, the elimination of cow’s milk protein seemed to be the more effective treatment. A recommendation is given to do a week trial of a hypoallergenic formula. They did find that many babies receiving breast milk had colic. It is thought that cow’s milk protein may be present in the breast milk of mothers who drink cow’s milk. The elimination of cow’s milk from the diet of breast-feeding mothers is suggested. They also found the anticholinergic drug dicyclomine to be effective, but 5% have side effects that include breathing difficulties, hypotonia, seizures, and coma (130).

Although not necessarily a treatment for colic, researchers have been studying the effects of introducing prebiotic oligosaccharides in formula milk on the gut of infants, particularly for those who are unable to receive breast milk. It has been found that infants fed prebiotics have a higher count of bifidobacteria and lactobacilli, lower pathogenic bacteria counts, and more acidic gut pH. Stools more resembled those of infants fed breast milk – softer and more frequent stools (131).

The Danish Chiropractor’s Association conducted a preliminary survey on the disorders of infants for which chiropractic consultations were sought and the outcome of the chiropractic care rendered. Seventy percent, or 132 of 189 of the consultations, were for infantile colic; the average age of the infants was 6 weeks. The average number of treatments was two to three over an average 1-week time period. Fifty-four percent (72 infants) were cured, 37% (48 infants) were improved, and no change was noted in the remaining 12 (9%). The improvement was considered to be associated with the care rather than spontaneous remission because of the age of the infants (127,128,132,133). A prospective cohort study that included 316 colicky infants by the same research group found that most improved within the first 2 weeks. Most adjustments were made to the upper cervical spine (134).

A 9½-month-old girl presented at a chiropractic office and was suffering from colic, irritability, and poor sleep. The history noted a difficult birth that resulted in cesarean section and an episode each of ear infection and the flu. The chiropractic evaluation showed postural deviations in the cervical spine and pelvis. Subluxations were found at C1 and T4-T6. The orthopedic and neurologic examinations were unremarkable. The lower cervical and mid-thoracic spine was adjusted manually whereas the C1 and sacrum were adjusted with an instrument using chiropractic biophysics protocol. After the first adjustment, the child slept a full night and was happy. Adjustments were given over a 3-week period with continued improvement in the sleep pattern, personality, and posture. She was not seen for a 3-week period, at the end of which some of the symptoms reappeared. Later adjustments continued improvement in her sleep, personality, and postural problems. The colic had abated (135).

In the Gonstead System, a commonly found subluxation in an infant with colic is C2. The doctor holds the infant under the axillae and slowly tilts the child laterally left and right. The doctor watches the head position. If the head does not laterally flex on one side and C2 is palpated as abnormal, C2 is adjusted by a spinous
process contact on that side in the sitting position with a primarily posterior to anterior line of drive. Subluxations could conceivably occur anywhere in the spine, necessitating a complete examination (136). Lawrence (137) states that one should evaluate the T5-T7 region.

Biedemann (121) found that of those who presented for manual therapy with incessant crying, about two-thirds had improvement in the week after receiving treatment. He found that those with KISS II syndrome (kinematic imbalance due to suboccipital strain syndrome type II, which is characterized by forced retroflexion of the head and neck, orofacial hypotonia, problems with swallowing, and excessive vomiting) and colic responded quite well.

A mother brought in a 12-week-old male infant for chiropractic evaluation. The birth was induced because it was thought that there was fetal distress. It was otherwise uncomplicated. He was the mother’s third child. She was given a Depo-Provera contraceptive injection 24 hours after delivery. She noticed that the infant had difficulty suckling from the right breast. Unlike her other children, he had difficulty developing a feeding schedule. His color was pale to gray as well. He had excessive flatulence, during which time he cried. Infant reflexes were unremarkable. Palpation of the right upper cervical area produced distress and fixation was noted at the atlas. The atlas was adjusted using infant togglerecoil technique. A week later, the mother stated that he had no gas and no difficulty breast-feeding for 5 days. After that, he had bowel gas and a hard stomach and was fussy. He had this pattern after adjustments. After 2 months of care, probiotics were recommended. His feeding pattern improved, he had less flatulence, he was more content, and stools were better. He continued to be breast-fed, got regular chiropractic check-ups, and continued with the probiotics (138).

An 11-month-old boy was brought in for a chiropractic evaluation at a chiropractic college clinic in 1949. He was suffering from infantile colic. At birth, he had a breech delivery. His fontanelles closed early, which gave him a somewhat microcephalic appearance. At age 5½ months he received a surgical lancing of his upper and lower teeth. At the time, this was a procedure in which the gums were opened up to facilitate normal dentition. Colic-type symptoms began to appear, and he would double over in pain and scream for extended periods of time. He vomited whatever he ingested. He had about 10 of these attacks a day. He was also constipated and required an enema. Medical doctors had placed him on a trial of anti-nausea drugs, at which time he was brought in for chiropractic care. He was having developmental delays and was not able to crawl, walk, or stand. He could only hold his head up momentarily in the prone position. He had minimal awareness of his environment and only recognized his parents. Sleep was poor, and he often woke up with colic during the night. He had a physical examination by the medical doctor on staff and, of course, had a chiropractic examination, which included cervical x-rays and neurocalograph evaluation. Two upper cervical toggle-recoil adjustments were given to the patient on the second and fourth days after the examination. He was monitored 6 days a week for 3 weeks. Daily diaries were kept by the parents. After the first adjustment, he was able to happily play for a couple of hours and was able to hold his head up higher and longer. That night, he slept all night. Colic symptoms did continue. After the second adjustment, he again slept through the night. Muscle coordination began to show improvement. He also began to be more alert and aware of his environment. After a few days, the colic attacks reduced significantly. One week after beginning care, he was able to eat solid food and keep it down. After 10 days he was talkative and doing well and only had one colic episode per day. He also began to have natural bowel movements. During the 3 weeks of care, he continued to improve (139).

Hewitt (140) describes an 8-week-old female infant who the mother described as a “fussy, high maintenance” baby. She was fitful, had a lot of flatulence, had difficulty falling asleep, and preferred nursing from the right breast. During the evaluation, the infant cried much of the time. The pregnancy was unremarkable, but the labor was long with a vaginal birth. At examination, heart beat was 160 bpm. She had a moderately weak suckling reflex and a hypersensitive Moro reflex. Other infantile reflexes were within normal limits. She preferred to keep her head in left rotation. Left suboccipital muscles were hypertonic, and restriction was noted in the atlas-axial level. Cranial examination via the Upledger protocols found problems in position and movements. The atlas was adjusted using the diversified method. Cranial bones were corrected using craniosacral therapy protocols. During the first adjustment, she fell asleep. After the first adjustment, she slept better and was able to nurse from the left breast more comfortably. She was checked five times over 3 weeks. The atlas was adjusted and cranial bones were corrected over the course of care. Suckling and Moro reflexes normalized. On the last visit, the mother stated that her infant slept better, was able to turn her head both ways freely, nursed comfortably from both breasts, and was not irritable. A follow-up call 9 months later found the child feeding normally, sleeping well, and able to turn her head both ways (140).

Sixteen infants with diagnosed acid reflux (n = 9) and colic (n = 7) were brought to a chiropractic office. The mothers of 10 reported difficult births that included vacuum suction, breech presentation, the umbilical cord was wrapped around the infant’s neck, and one “stuck in the birth canal.” Age range was 2 months to
11 weeks. Examination and care followed the protocols of the International Upper Cervical Chiropractic Association. One case was an 11-month-old boy who had a healthy history and normal birth. Since birth, he could not turn his head to the left, and he had bloody stools since 2 weeks of age. He was diagnosed with acid reflux and prescribed Zantac. He frequently spit up, had projectile vomiting, was excessively irritable and cried, and was unable to sleep more than 1 to 2 hours. After the examination and x-ray, the atlas was adjusted in a knee chest position with the head turned. On the second visit a week later, the mother said there was marked improvement and exam findings were such that no adjustment was given. Reflux symptoms improved, and medication was stopped by the mother. Six weeks later, the child was checked and no adjustment was given. He slept well, often through the night, and turned his head freely; acid reflux symptoms were absent and no drugs were used. These results had continued when checked a few months later. The same protocols were used with the other 15 cases. All were evaluated over a 2- to 8-week period of time and all were symptom-free after the chiropractic care was provided (141).

A study by researchers at the Anglo-European College of Chiropractic surveyed the parents of 2- to 3-year-old children. The children had had colic as infants and the survey was to study the long-term effects. Fifty of the children for whom surveys were returned had received chiropractic care for colic (from one chiropractic office), and there were 45 who had not received chiropractic care (from day care centers). They found that more children who did not receive chiropractic care for colic continued to have temper tantrums more than those who had received chiropractic care. Sixty percent of those who received chiropractic care rarely or never had a temper tantrum compared with 27% who did not receive chiropractic care. Of the chiropractic group, 78% fell asleep within 20 minutes and 68% slept through the night versus the non-treatment group, which was 38% and 33%, respectively (142).

Miller et al. (143) did a double-blind, placebo-controlled trial of 102 healthy, full-term infants younger than 8 weeks of age who presented to a chiropractic college with excessive crying. The 33 infants in group A received routine chiropractic care, which was observed by the parents. The 35 infants in group B received the same care but parents were blinded to group allocation. Group C (34 infants) received no chiropractic care and the parents were blinded to group allocation. Daily diaries were kept on the amount of crying. The average total baseline crying was 321 (±134) minutes per day. Group A had a 160-minute reduction by the 14th day of the trial. Group B had a reduction of 143 minutes and group C a reduction of 70 minutes. Caregivers’ impression of overall improvement at 2 weeks was 91% for group A, 77% for group B, and 9% for the untreated group C.

Miller and Croci (144) presented a case of a 4-week-old boy who had difficulty settling down and would cry when placed supine (the position for prevention of sudden infant death syndrome [SIDS]). When one attempted to hold him, he would arch his back and head to a position that seemed to be more comfortable for him. His sleep/wake cycle was normal. When breast-feeding, he would often pull away and show signs of discomfort. At 2 weeks of age, he began to become irritable. The physical examination was unremarkable. The chiropractic examination showed segmental dysfunction at C1-C2. During the exam, when he hyperextended his spine, he resisted attempts to move him to a more normal posture and made a high-pitched cry. Light pressure was put over the posterior aspect of the atlas transverse process. The suboccipital muscles were gently stretched. The lumbar spine and pelvis were mobilized. Care was provided twice per week for 2 weeks and once per week for 2 weeks. Over the course of care, symptoms resolved. He slept well and comfortably on his back, ate well, and cried primarily when he was hungry.

Hipperson (145) wrote of two cases of infantile colic. The first is a 7-week-old boy. He would sleep briefly and, upon awakening, would cry for 4 to 5 hours. Although the pregnancy was unremarkable, the birth was difficult. There was a long labor and his head was “engaged” for 16 hours. Fetal monitoring found low fetal heart rate in the final hour, so a forceps birth was done. He had left facial bruising and mild jaundice. He was breastfed. When feeding, he seemed hungry but had reflux. Suckling reflex was intact. His head was misshapen. The abdomen appeared bloated and he would scream when pressure was put over the right lower quadrant of the abdomen in the area of the ileo-cecal valve. Neurological testing was unremarkable. Vertebral subluxations were found at C1, T4, and T8, and the right sacroiliac joint was restricted. Diversified adjustments were made to the four segments. Cranial work was also done. After four treatments, symptoms began to subside. He was able to sleep better, was calm after feeding, and did not have episodes of prolonged crying. The reflux resolved after seven visits. After 3 months of care, he slept 10 hours a night and was asymptomatic.

Hipperson’s (145) second case was a 10-week-old infant who had colic for 5 weeks. Screaming occurred during the entire day with knees drawn up, a red complexion, and rigidity of the body. He had non-projectile vomiting daily. He preferred nursing from the right breast. The evening feed aggravated the symptoms. He did sleep well at night. Like the previous case, the pregnancy was normal, but labor was long and difficult. He got stuck in the birth canal so the birth was induced. He was unable to feed for the first 24 hours. When examined,
he appeared well fed and had good weight gain. Tension was noted over the diaphragm. The rest of the examination was unremarkable. The chiropractic examination found vertebral subluxations at C1, T2-T4, and the right sacrum. Those regions were adjusted, as was the cranium. Six treatments were given over a 3-week period. No episodes of colic occurred after the first adjustment, and he was asymptomatic after 3 weeks. The vomiting, hiccupping, and asymmetrical feeding resolved.

This report is of a 2-week-old boy who presented with excessive crying, abdominal distention, constipation, and gas. He would cry for hours at a time. Ultrasounds during the pregnancy brought up concerns about his kidneys. Birth was relatively normal but antibiotics were begun to prevent kidney infection. These were discontinued when the crying started. Sleep was poor. Hypertonicity was found in the muscles superior to the right iliac crest and bilaterally in the suboccipital area. Chiropractic adjustments to the sacrum were given following the protocols of the Logan basic technique. At the initial visit he was crying and in distress. He belched during his first adjustment and had a bowel movement before leaving the office during the first visit and immediately after the first adjustment. He vomited immediately after the first few adjustments. After five visits, his bowl movements became regular. If an appointment was missed, distress was noted and abated with adjustments. After 16 adjustments, colicky behavior and constipation resolved. Findings also began resolving. Crying only occurred when he was hungry or tired. Sleep improved (146).

Klougart et al. (147) did a study of 316 cases of colic through several chiropractic offices. Colic began at a median age of 2 weeks old. The median age that chiropractic care began was 5.7 weeks. Mothers were given daily diaries to be filled out for 28 days. Ninety-four percent of the patients had upper cervical adjustment solely or in combination with mid-thoracic adjustments. Ninety-four percent of the mothers reported that their infant had “no colic” or “colic improved” within 14 days after beginning chiropractic care.

There have been a few cases of infants brought with ALTEs after being give an European-made homeopathic medication sold for colic called Gali-col Baby. It seems to be a blend of various substances. A few of the infants were given doses above that recommended by the manufacturer. A variety of symptoms were noted, including apnea, cyanosis, stiff body or flaccidity, and rolling eyes (148).

Massage is thought to be beneficial for the reduction of colic symptoms (149).

Because of the nature of this condition, there are no objective tests for it. Parent diaries tracking the number of hours the infant cried each day is one means of recording. Another factor to remember is that colic usually ceases spontaneously within a few weeks.

The urinary bladder is a reservoir with three orifices: one from each of the two ureters, which carry urine from each kidney, and one exit orifice to the urethra. The three orifices form the corners of the trigone of the bladder. The bladder wall has three layers: a serous layer, which is the peritoneal covering, a triple layer detrusor muscle, and a mucous membrane (167).

The detrusor muscle surrounds the bladder, and its contraction is necessary for voiding. The sphincter muscle controls the outflow to the urethra by contracting to hold urine in or relaxing to void.

Unfortunately, the neurological control of the urinary bladder is somewhat vague. The urinary bladder seems to be controlled by the coordination of the somatic, sympathetic, and parasympathetic systems. Parasympathetic preganglionic nerves from S2 to S4 cord levels form the pelvic splanchnic nerve and supply motor control to the bladder. The parasympathetic impulses contract the detrusor muscle and relax the sphincter muscle, which allows urination to occur (168,169). Sympathetic fibers are from the T11 to L2 levels and are thought to be inhibitory to the bladder (169). The external sphincter is supplied by the pudendal nerve, which arises from S2 to S4 spinal nerves (170).

Afferent fibers accompany the efferent supply to the bladder. Afferent fibers that respond to distention of the bladder initially are received at the T12-L2 dermatome levels and later at the S2-S4 levels. These impulses ascend the spinothalamic and spinoreticular tracts. The sensation of bladder fullness, often conscious, is thought to be of sympathetic origin (171). Unconscious information from the bladder, for example, unconscious sensations of bladder fullness that cause detrusor contraction, is thought to be via the parasympathetic supply (171). The somatic afferent fibers are thought to convey conscious sensation of urine flowing through the urethra via the pudendal nerve (171). Receptors thought to respond to pain as a result of overdistention form the vesical nerve plexus, which is continuous with the inferior hypogastric plexus (169).

There are nerve axons and nerve cell bodies found in the bladder wall. These are neither cholinergic nor adrenergic, but some are peptidergic. The function of these nerves is unknown (171).

The neurologic control of micturition requires complex coordination of the nervous system and is still largely speculative, in particular, its supraspinal control (172).

Behavior modification has been tried, with mixed results. Dry bed training and an enuresis alarm for children older than age 7 seems to be effective in about 70% of cases (163,164,173). An alarm is useful for children with small bladder capacity. Unfortunately, drugs with low effectiveness have been prescribed more frequently than the more effective behavior training with alarms (164).

Drug therapy usually consists of imipramine or desmopressin. Some have been able to remain dry during the course of treatment with desmopressin intranasal spray (2,6). Prolonged effectiveness after the termination of treatment has been mixed (12% to 31%) (160,165,173,174,175). Although some studies show greater effectiveness (176), it seems to be most useful on an occasional basis in social situations, such as sleeping away from home (165). Desmopressin is a synthetic analog of arginine vasopressin or antidiuretic hormone (ADH). The altered chemical structure of desmopressin from ADH emphasizes its antidiuretic tendencies and decreases its vasoconstriction or pressor activities (177). Its side effects seem to be uncommon and less than those of imipramine. The effects include hyponatremia, water intoxication, seizures, allergic reaction, and increased blood pressure (177,178).

Imipramine is a tricyclic antidepressant used in some cases of enuresis. The combination of imipramine and desmopressin is not recommended (179).

Bladder stretching exercises have been tried with children with small bladder capacity. It is effective in 35% (162,163).

One study compared waking the child about 1½ to 2 hours after they are asleep, taking them to the bathroom to urinate, and returning them to bed. Some children were required to recite a password to make certain they were awake. Others did not require a password. Some children were on a reward system. The final group was the controls. The groups that were awakened had a high percentage of becoming dry; oddly enough, the higher percentage of becoming dry was in the nonpassword group. Many in the control group became dry within 2 years (180).

There are many reports of the benefits of chiropractic care to reduce or resolve persistent or chronic cases of nocturnal enuresis. Unfortunately, most do not follow the recognized protocol for determining effectiveness or do not have long term follow-up, so they fall in the category of “compelling.” Most involve one or a handful of cases so are often considered to be anecdotal.

Blomerth (181) describes a case of an 8-year-old boy with primary nocturnal enuresis who wet the bed several days out of a week. This patient was receiving concurrent medical care for asthma. The mother checked the sheets on a daily basis. He was adjusted in the lumbar spine with follow-up 4 weeks later. At follow-up the mother stated that the bedwetting had ceased. Two months later, he had two wet nights the previous week that appeared to begin after a fall off of a toboggan. The lumbar spine was adjusted and bedwetting ceased. At 1-year follow-up, a recurrence was noted that ceased after two adjustments. At 2 years, another recurrence was noted that ceased after spinal adjustments. The child was not informed that the chiropractic care was for bedwetting because he had concurrent low back pain.

Bachman and Lantz (182) describe a case of a 22-month-old boy who received chiropractic care for asthma, which ceased with care. After fall a couple of months later, asthma reappeared along with nightly enuresis. Both conditions ceased after three visits. Both recurred after another fall and again ceased after chiropractic care was administered. During a reevaluation more than 1 year later, it was reported that symptoms of neither had recurred.

Marko (183) presented two cases. The first is a 9-year-old boy who suffered from daily bedwetting his entire life. During the first 6 months of receiving chiropractic adjustments, the day of receiving the adjustment and possibly the following day, he would be dry before being wet again. Changes in adjustments were made and
he was adjusted diversified with protocol of chiropractic biophysics. After 1½ years of care, he is dry one-half to two-thirds of the time. The second is another 9-year-old boy. After being seen by another chiropractor, he was dry some of the time. At this point he received diversified and chiropractic biophysics adjustments. After 2 to 3 months, he had been dry with occasional wet nights (183).

A case of an 8-year-old girl who wet the bed daily and had epilepsy, heart murmurs, hypoglycemia, and attention deficit disorder is described by Langley (184). Adjustments were given in the upper cervical spine. After 6 months of chiropractic care, the bedwetting had resolved. After 1 year of care, it had not returned.

A chiropractic study using appropriate protocol was conducted by LeBoeuf (185), who used senior chiropractic students as the clinicians rather than experienced chiropractors. This is not to cast aspersions on the skill of student clinicians, because there are many as skilled or more skilled than many practicing chiropractors; however, as most people know, experience does make a difference, and vertebral subluxations need to be carefully localized and very specific adjustments given. Knowing when to stop adjusting is very important in these cases because, as many clinicians have found, adjusting beyond “correction” of the subluxation seems to coincide with resumption of bedwetting.

Forty-six children with nocturnal enuresis were studied at the Palmer Institute of Research. At the end of the study, those who received conventional manual adjustments had a mean frequency of wet nights of 7.6 nights per 2 weeks versus a sham treatment group with a mean of 9.1 wet nights per 2 weeks (186).

McCormick (187) wrote of a 10-year-old girl who was examined chiropractically with complaints of long-term bed wetting that increased to one to two times daily during the year before presentation. She also had daytime enuresis. Palpation findings were noted in the cervicothoracic, thoracic, and upper lumbar spine and the sacroiliac joints. Various techniques were used to adjust the spine. In addition, omega-3 and vitamin E were recommended. During the first week of care, episodes of wetting went from 14 to 4 per week. After several weeks of care, episodes averaged about 5 per week.

A 4-year-old who was having asthma, snoring, and bedwetting presented to a chiropractic office (this case has been presented earlier, in the section about asthma). The authors noted that bedwetting ceased after 6 weeks of care, although no description of the bedwetting was given (188).

Wells (189), in 1939, stated that the chiropractor should look for subluxations at the L5 level, sacroiliac joints, and T11-L2 region.

Many chiropractors have found that correction at the sacral segment or upper lumbar/lower thoracic spinal levels, but not limited to those levels, seems to have a positive effect on many pediatric patients suffering from nocturnal enuresis. It has often been stated that sacral segments S2 or S3 may require adjustments, but that is not always the case. If the sacral segment is involved, there should be a “V” appearance (posterior widening of the sacral segment rudimentary disc space between the involved segment and the superior segment), as well as palpable swelling and tenderness over the tubercle. If those findings are not seen, it is necessary to search. Sometimes correction begins in the sacrum but then shifts to another area, such as the thoracolumbar region. “Overadjusting” the dysfunctioning vertebra may cause a resumption of symptoms; therefore, carefully following the patient’s symptoms from visit to visit is necessary to prevent this. It is often helpful to find out if the child drinks before going to bed and, if so, to cease or restrict it. Occasionally, it may be a case of the child simply likes to wet the bed.

A detailed history is obviously important. If possible, a baseline observation of 1 month before care begins can confirm the severity. The parents can keep a diary noting whether each night was dry or wet. A common means of determining a successful outcome is 14 consecutive dry nights. Follow-up evaluations or queries should be made for at least 2 years. Remaining dry for 2 years is considered a complete success (160).

Medical treatment of otitis media, particularly AOM, has been changing significantly. Drug-resistant microbes have made antibiotic therapy complicated and have become more prevalent. Guidelines in many countries now recommend observation or “watchful waiting” without the use of antibiotics (204). Recommended antibiotics include amoxicillin and clavulanate. Both of these drugs are recommended in high doses, either singly or in combination. It has been noted that those who are taking antibiotics require less drugs and a shorter time duration for pain management than the “watchful waiting” children (204). There is major parental resistance to “watchful waiting,” so is little used, according to a 2007 survey (204).

Between 1977 and 1986, prescriptions for antibiotics for children under the age of 10 increased by 51% but their use among the general population declined (205). In 1986, 42% of all antibiotics prescribed to children were for otitis media (205). In studies of antibiotic-steroid combination drug therapy, antibiotics tended to slow resolution of OME (190). Studies have supported a less interventive approach for most cases of OME—that is, observation or “watchful waiting”—without resulting in impairments on language acquisition, attention, or behavior (206).

Antibiotics are not without risks. The most common adverse effects are diarrhea or other gastrointestinal tract problems or dermatological reactions. Some adverse reactions, though rare, can be quite serious (202). Rosenfeld et al. (203) did not recommend the use of anti-microbial drugs because of the lack of longterm efficacy, particularly for routine management. The 2004 guidelines for AOM for children in day care centers, created by the American Academy of Pediatricians and American Academy of Family Physicians, recommends amoxicillin alone in most cases or amoxicillin/clavulanic acid in moderate to severe cases as the first therapy of choice (204). The seven-valent pneumococcal conjugated vaccine, PCV7, has been used to prevent Streptococcal pneumoniae AOM. It is less effective in infants (207). The rise of antibiotic-resistant bacteria, particularly in the close environment of a day care center—children who attend day care often receive multiple courses of antibiotics—reduces the effectiveness of the antibiotics of choice and of PCV7 as well (208). A new vaccine is being tested at the time of this writing, pneumococcal-HTHi-protein-D conjugate vaccine (197). A 2007 study found that many pediatricians and family physicians did not follow the 2004 guidelines and often used higher doses of amoxicillin for nonsevere AOM and chose cefdinir rather than the recommended amoxicillin/clavulanate for the second choice if amoxicillin fails (204). As we know, the indiscriminate use of anti-microbials, as well as their use in animals whose meat and organs we consume, has led to drug-resistant versions of the microbes associated with otitis media and other disorders.

Antihistamines and decongestants are not recommended for the treatment of OME because no efficacy has been demonstrated (203). Steroids such as prednisone and prednisolone are often used to treat otitis media (209). In 2004, steroids were not recommended because they do not have long-term efficacy (203).

When drugs fail, surgical procedures are often employed. Myringotomy with or without tympanostomy tubes is the usual surgical procedure done for OME, but the 2004 guidelines do not recommend myringotomy alone because it does not have long-term efficacy (203). A study of 6,429 children who had tympanostomy found that 42% were deemed appropriate, 35% equivocal, and 23% were considered to be inappropriate (210). Another study of 5,400 children found that tympanostomy did not have any value as a primary treatment or in combination with antibiotics (210). A common reason for the placement of tubes is the possibility of delayed language acquisition because of hearing impairment. Research has shown no significant delays with language development due to OME (197,211). A study of infants with persistent, bilateral OME were split into those receiving tympanostomy tubes and those who were not (“watchful waiting”). At 12-month follow-up, those who did not receive tubes had OME longer, but there was no significant difference in either receptive or expressive language development or quality of life (212). The efficacy of tympanostomy tubes is considered to be inappropriate or equivocal in most cases except if there are marked otoscopic findings, antibiotics have failed, and the condition has continued for 90 to 120 or more days (190). A study in Philadelphia, Pennsylvania, found that 6% of the 2,253 children in the study group received tubes by the age of 2 years (195). The decision to perform tympanostomies were found in more than 90% of cases of short-term OME, which is not in accordance with the 1994 guidelines of the American Academy of Pediatrics, American Academy of Family Medicine, and American Academy of Otolaryngology—Head and Neck Surgery, and more than two-thirds of the time, based on criteria used by Keyhani et al. (195) in a New York metropolitan area. Paradise et al. (213) found that in children with persistent otitis media younger than the age of 3 years, promptly inserting tympanostomy tubes will not measurably improve developmental outcomes when tested at age 3 years. In one study, reoccurrence rate of effusion after tympanostomy tube insertion was 98% (214). Rovers et al. (211) compared tympanostomy tube insertion to “watchful waiting.” The authors studied children, 1 to 2 years of age, who had persistent bilateral OME for 4 to 6 months. Some received shortterm tympanostomy tubes whereas the other group did not (the “watchful waiting” group). The tubes benefited hearing for 6 months, but both groups were similar at 12 months. Other studies, usually using somewhat older infants and children, had similar findings. Also, the tubes were often non-functional after a few months (211). There are post-surgical risks with tympanostomy, which include persistent perforated tympanic membrane, cholesteatoma, and tympanosclerosis, as well as risks from sedation and anesthesia (215,216).

Adenoidectomy or tonsillectomy, singly or with myringotomy with or without tympanostomy tubes, is not a recommended procedure for children younger than age 3 without pathology of the adenoids, according to an AHCPR Panel consensus, which is reiterated for all children in the 2004 update (203). In children younger than
age 15, there is a 1 in 10,000 risk of adverse effects from general anesthesia. Significant postoperative bleeding is another risk. In Ontario, Canada, between 1968 and 1973, the mortality rate of combined adenoidectomy and tonsillectomy was 2 in 51,938. With the combined procedures, a 1992 study of operations between March 1987 and April 1990 found a rate of hemorrhage of 0.49% (190). Tonsillectomy for OME is not recommended without signs of tonsillar pathology (190,203).

The direct and indirect cost of allopathic medical care of 2 year olds was $1.09 billion. Average per-patient cost of drug therapy was $406. Cost for myringotomy and tympanostomy tubes averaged $2,174 (with adenoidectomy, $3,433) (190).

The recommendation for children with OME who are not considered at risk for hearing loss, learning delays, and learning problems is “watchful waiting” (203).

There are numerous case studies of children with otitis media who received chiropractic care and had positive results but were resistant to allopathic medical care. Fallon (217) presents a case of a 3-year-old boy who had four previously diagnosed episodes of otitis media within the 7 months before seeking chiropractic care. All episodes were treated with antibiotics by a pediatrician. The physical examination was normal except for bulging and swelling of the left tympanic membrane with loss of the light reflex. Chiropractic subluxation complexes were found at the occiput, C4, and T6. Laboratory work-up was normal except a slightly depressed white blood cell level. He was seen five times over a 9-day period. On the first day, the occiput was adjusted. On the second day, C4 and T6 were adjusted. On the fifth and ninth days, the occiput was adjusted. After the first adjustment he had an overnight elevation of his temperature, which returned to normal by morning. Tympanometric findings showed improvement with each visit and appeared to be normal by the ninth day.

Fysh (218) briefly described two cases as an illustrative introduction to the presentation. The first case was a 22-month-old girl with persistent otitis media for the previous 8 months. One chiropractic treatment was given and the otitis cleared within 24 hours. At 2-week follow-up, no signs of otitis media were present. The second case is a 16-month-old boy with otitis media for the previous 5 months. During the 5-month period, six trips were made to the emergency room for treatment. He had been on continuous antibiotic therapy during the time. One chiropractic treatment was given and the condition cleared up. The 4-week follow-up showed no recurrence. Presumably, the “chiropractic treatments” were spinal adjustments and “clearing up” means symptomatic relief and negative tympanoscopic evaluation.

Burnier (219) notes two male children, ages 6 and 9, who suffered from chronic ear infections, for which antibiotics were given. C2, C3, T12/L1 subluxation were found on one child and occiput/C1 and sacral subluxations on the other. Adjustments were given. Three years after beginning chiropractic care, no drugs were needed. No other information was given in these cases.

In a retrospective study of 46 children up to age 5 years who had been seen in a chiropractic office and had complaints of ear infections or discomfort. Ninety five episodes of ear infections/discomfort were noted among the 46 children. Of these children, 55% were boys and 45% were girls. Antibiotic use had been used by 62%. Multiple previous episodes were noted in 61%. Of the rest, 24% had one previous episode and 15% had no prior episodes; the others were thought to have ear discomfort. Three had tympanostomy procedures. Chiropractic care consisted of the use of an activator instrument as well as pelvic blocking (sacro-occipital technique) and applied kinesiology. Outcome was based upon clinical signs and symptoms. Ninety-three percent were noted as improved (214).

Saunders (216) presented a case of a 3½-year-old boy with constant and odorous discharge from both ears. An exam detected a slight hearing loss, and a consideration was being made for myringotomy and tympanostomy tubes. At presentation, chiropractic examination found fixations in the cervical spine and SCM muscle, and hypertonicity and restrictions in the mid-thoracic spine. Adjustments were given to the cervical spine and light activator treatment to the thoracic spine. Over a 2-week period, the child was seen four times. On the second visit, the parents did not find discharges on his pillow or have to clean his ears as occurred daily before the adjustments. Three months after chiropractic care, hearing improvements were found when tested. Ceruminum continued to accumulate in his ears and were treated with oils. No further incidences of OME occurred.

Heagy (220) presented four cases of chronic otitis media. The first was a 14-month-old boy who had had 13 antibiotic series. He had an unremarkable birth. Fixation was found between the occiput and C1, along with muscular changes and edema at that level. Adjustments were made at that level. After 6 weeks of chiropractic care, his medical doctor stated that he was free of otitis media and, after 13 months, he continued to be free of it. The author stated that she contacted the child’s pediatrician to work with him on cases of otitis media. She described that he was “appalled” and “quite upset” by the idea (220).

A second case by Heagy (220) was a 6-year-old who had a forceps delivery after a long labor. He presented with chronic sinusitis and ear infections. He had constant sinus drainage and four to five sinus infections
that twice a year resulted in ear infections. Potential subluxations were found in the upper cervical and mid-thoracic spine and at the lumbosacral area. The cervical and thoracic regions were adjusted. One year after initiating chiropractic care, he had not had a recurrence of sinusitis or ear infection, nor had he missed school.

The third case described by Heagy (220) was a 2½-year-old girl whom the parents brought in for wellness care. Palpation found subluxation in the upper cervical spine, which was adjusted. Care was given over a 4-month period. Two years after being last seen, the parents brought in the patient, who began suffering from ear infections that caused hearing loss and pain. Signs of subluxation were found in the upper cervical spine, T4, and L5. Adjustments were given to these areas via diversified adjustments. Over a 5-month period of time, the patient was infection free. She had some episodes of sinusitis. The patient was happier and most of the hearing loss was restored.

Heagy’s (220) fourth case was a 7-year-old male child. At least once a year he suffered from ear infections. Increasingly stronger doses of antibiotic were given. A tympanostomy was recommended. Subluxations were found in the upper cervical spine and at L5. Chiropractic adjustments were given to those segmental levels. After a few months, he was free of ear infections, runny nose, and sinus drainage. After 4 years of regular chiropractic check-ups, he had not had any incidences of ear infections (220).

A case of a 5-year-old boy was written up by Peet (221). At age 3 months he was placed in day care. Since that time he had had fevers, sinus and upper respiratory infections, and otitis media. He had been on courses of amoxicillin and other antibiotics and had tubes inserted. In spite of the interventions, the infections continued to occur. Spinal distortions were found via chiropractic biophysics technique protocols and chiropractic adjustments using chiropractic biophysics were done. On the second visit, ear drainage had ceased and the ear canal and tympanic membranes had better color. Over the course of several months, he had one incident of OME, which cleared after chiropractic adjustments and without the use of antibiotics.

A 19-month-old boy was brought in for chiropractic care. He had a history of recurrent ear infections since just after birth. He was found to have anterior and left head translation. Care using chiropractic biophysics technique protocols was rendered multiple times a week for 3 weeks and then once per every 2 to 3 weeks at the time of the writing. Since care began, he has had a few periods of congestion but no ear infections (222).

Webster (223) presented two cases of otitis media. Unfortunately, not much information was presented. The first was a 4-year-old boy who had a diagnosis of otitis media. He had 2 years of antibiotic treatments without results and tube insertion was being advised. He also complained of stomach cramps and diarrhea that may have been caused by the antibiotics. Subluxations were found in the upper cervical spine, which were adjusted by toggle adjustments at intervals of two per week. After 2 weeks of care, there was improvement in the symptoms. The second patient was a young male child who had chronic ear problems. Over a 3-year period he received antibiotic treatments without sufficient results and tubes were inserted. After those failed to help, a second set was inserted and more antibiotics were given. Subluxations were found in the upper cervical spine and were adjusted. On the fourth visit, he had no ear complaints and none were made over nearly 2 months of care.

Twenty-two children with AOM who ranged from 9 months old to 9 years old received Toftness adjustments. Of these, nine were girls and 12 were boys. otoscopic examination was made of the tympanic membrane before and after the adjustments. The children presented with red and bulging tympanic membranes and moderate fever. In a 2-week period, the children received between three and six adjustments. Symptoms reduced significantly (210).

Northwest College of Chiropractic conducted a prospective, parallel-group, observer-blinded randomized feasibility study on chiropractic spinal adjustments versus sham adjustments for OME. Full-spine adjusting was done, with emphasis on the upper cervical spine. In the sham adjustment group they did static and motion palpation and light touch on specific spinal segments. Otoscopic and tympanometric measurements were done, as were outcome measures of symptoms, sleep patterns, need for medical care, and medications. There were 10 treatments over a 4-week period of time. Those receiving chiropractic spinal adjustments, on average, had fewer symptom days at the end of active treatment and at follow-up 4 weeks later. This seems to be more of a feasibility and methodology study rather than an active outcome study on chiropractic care of OME (215).

An 8-year-old girl with a 3-year history of bilateral otitis media, occipital cephalgia, cervicalalgia, and sinus infections was brought in for chiropractic care. There was no history of trauma. At birth, the umbilical cord was wrapped around the child’s neck and for 2 minutes the child did not breathe nor cry. For the otitis media, she had received several rounds of antibiotics, sinus surgery, and two tympanectomy surgeries bilaterally. Symptoms persisted. Palpation noted severe cervical muscle tension bilaterally from the occiput to the midcervical spine. Cervical spine motion was restricted. The lateral cervical x-ray showed a reversed cervical curve. She was seen on 29 visits over a 3-month period. Trigger point therapy and an activator instrument was used on the first four visits. Mirror image adjustments
were done using the instrument. From the fifth visit on, diversified cervical adjustments were given. Clinical chiropractics of posture (chiropractic biophysics) protocol was used from visit 8 along with continued chiropractic spinal adjustments. Traction was also initiated. After 1 month of care, headaches, sinus pain, and ear pain had stopped and a third tympanectomy was cancelled. Home exercise protocols were also recommended. Postx-rays at 3 months showed a normal cervical curve on the lateral film. At 12-month follow-up, the patient was symptom-free (224).

A 9-month-old boy with a history of recurring ear infections was brought in for chiropractic assessment. Antibiotic treatments were ineffective, and myringotomy and tympanostomy tube insertion had been recommended. Birth was by cesarean section. No known trauma was noted. Ear infections began at age 4 months. Antibiotics were given. Ear infections occurred every 3 weeks. Claritin was provided for allergies. At presentation, in addition to the ear infections, a slight torticollis was found. After examination, C2 was adjusted using an infant toggle head piece that was developed by Dr. Larry Webster. Light pressure was also done over the sinuses. Nutritional recommendations were also made. On the third visit, the patient was said to be doing better and sleeping well. At that time, C1 was adjusted on the same headpiece and the sacrum was adjusted using an activator instrument. Non-force cranial adjustments were also given. The second week, the mother said that the infant was not sleeping well and was pulling on the right ear. Ears were clear and no fluid found. C1 and T1 were adjusted. Adjustments were also given twice more during the week. C1, T1, and sacrum were adjusted on the three visits during the third week. Ear pulling had ceased. The patient was seen twice a week from the fourth week. When examined during the fifth week of care, there had been no ear infections and he slept better. During the seventh week of care, visit to the ear nose and throat specialist found the ears clear and that tubes would not be needed (225).

The AHCPR Panel could not find randomized, controlled studies on the efficacy of chiropractic care or other nonallopathic procedures in the treatment of OME. They did recommend future studies because these types of therapy were inexpensive and had no apparent notable risk of morbidity (190).

There is concern about the safety of chiropractic adjustments or spinal manipulative therapy in the pediatric population; most or all of it is opinion rather than fact. A retrospective study of children from the ages of 1 day old to 19 years old found no complications after osteopathic manipulative therapy. Of the 502 patients, 31 had some aggravation of symptoms, but most resolved in the first 24 hours or before the follow-up visit (226).

Nsouli (227) found that 81 of 104 children with otitis media had allergies to food—one-third to milk and onethird to wheat. When the specific food was removed over a 4-month period, 70 of the children had improvement in the ear. When the 70 children were given the food back, the otitis media worsened (227). An ear nose and throat specialist placed children referred for tympanostomy on a diet free of dairy products and found that three-fourths of the children did not require surgical intervention (205). Kohl reports a similar resolution by taking an infant with chronic ear infections off of dairy formula (202). Infant formula often contains sugars, particularly corn syrup (high fructose corn syrup). An infant may have a difficult time digesting it properly. If this is compounded by antibiotics that destroy the bowel flora, it could lead to problems such as diarrhea and ear infections (202).

Backon (228) suggests that prolonging breast-feeding might prevent recurrent otitis media. A researcher found high levels of arachidonic acid (PGE-2) metabolites in patients with otitis media. Breast milk contains gammalinoleic acid and dihomogamma-linoleic acid, which converts to prostaglandin E1. Prostaglandin E1 may prevent otitis media by reducing inflammation (228).

The temporomandibular joint and altered bite is thought to be associated with some cases of otitis media.

Much lay information has been provided by Schmidt on otitis media through a book (229) and an article in a magazine (230).

Outcome studies for otitis media usually involve measurement systems, such as otoscopic evaluation, tympanometry, fluid culture studies, and/or pneumatic otoscopy. Outcome questionnaires that query parents are helpful as well.