Chiropractors in Australia will not be able to perform spinal manipulation on children under the age of two once more, following health concerns from doctors and politicians.

But what is the spinal treatment at the centre of the controversy? Does it work? Is there evidence of harm?

We’re a team of researchers who specialise in evidence-based musculoskeletal health. I (Matt) am a registered chiropractor, Joshua is a registered physiotherapist and Giovanni trained as a physiotherapist.

Here’s what the evidence says.

Remind me, how did this all come about?

A Melbourne-based chiropractor posted a video on social media in 2018 using a spring-loaded device (known as the Activator) to manipulate the spine of a two-week-old baby suspended upside down by the ankles.

The video sparked widespread concerns among the public, medical associations and politicians. It prompted a ban on the procedure in young children. The Victorian health minister commissioned Safer Care Victoria to conduct an independent review of spinal manipulation techniques on children.

Recently, the Chiropractic Board of Australia reinstated chiropractors’ authorisation to perform spinal manipulation on babies under two years old. But this week, it backflipped, following heavy criticism from medical associations and politicians.

What is spinal manipulation?

Spinal manipulation is a treatment used by chiropractors and other health professionals such as doctors, osteopaths and physiotherapists.

It is an umbrella term that includes popular “back cracking” techniques.

It also includes more gentle forms of treatment, such as massage or joint mobilisations. These involve applying pressure to joints without generating a “cracking” sound.

Does spinal manipulation in babies work?

Several international guidelines for health-care professionals recommend spinal manipulation to treat adults with conditions such as back pain and headache as there is an abundance of evidence on the topic. For example, spinal manipulation for back pain is supported by data from nearly 10,000 adults.

For children, it’s a different story. Safer Care Victoria’s 2019 review of spinal manipulation found very few studies testing whether this treatment was safe and effective in children.

Studies were generally small and were of poor quality. Some of those small, poor-quality studies, suggest spinal manipulation provides a very small benefit for back pain, colic and potentially bedwetting – some common reasons for parents to take their child to see a chiropractor. But overall, the review found the overall body of evidence was very poor.

However, for most other children’s conditions chiropractors treat – such as headache, asthma, otitis media (a type of ear infection), cerebral palsy, hyperactivity and torticollis (“twisted neck”) – there did not appear to be a benefit.

The number of studies investigating the effectiveness of spinal manipulation on babies under two years of age was even smaller.

There was one high-quality study and two small, poor quality studies. These did not show an appreciable benefit of spinal manipulation on colic, otitis media with effusion (known as glue ear) or twisted neck in babies.

Is spinal manipulation on babies safe?

In terms of safety, most studies in the review found serious complications were extremely rare. The review noted one baby or child dying (a report from Germany in 2001 after spinal manipulation by a physiotherapist). The most common complications were mild in nature such as increased crying and soreness.

However, because studies were very small, they cannot tell us anything about the safety of spinal manipulation in a reliable way. Studies that are designed to properly investigate if a treatment is safe typically include thousands of patients. And these studies have not yet been done.

Why do people see chiropractors?

Safer Care Victoria also conducted surveys with more than 20,000 people living in Australia who had taken their children under 12 years old to a chiropractor in the past ten years.

Nearly three-quarters said that was for treatment of a child aged two years or younger.

Nearly all people surveyed reported a positive experience when they took their child to a chiropractor and reported that their child’s condition improved with chiropractic care. Only a small number of people (0.3%) reported a negative experience, and this was mostly related to cost of treatment, lack of improvement in their child’s condition, excessive use of x-rays, and perceived pressure to avoid medications.

Many of the respondents had also consulted their GP or maternity/child health nurse.

What now for spinal manipulation in children?

At the request of state and federal ministers, the Chiropractic Board of Australia confirmed that spinal manipulation on babies under two years old will continue to be banned until it discusses the issue further with health ministers.

Many chiropractors believe this is unfair, especially considering the strong consumer support for chiropractic care outlined in the Safer Care Victoria report, and the rarity of serious reported harms in children.

Others believe that in the absence of evidence of benefit and uncertainty around whether spinal manipulation is safe in children and babies, the precautionary principle should apply and children and babies should not receive spinal manipulation.

Ultimately, high quality research is urgently needed to better understand whether spinal manipulation is beneficial for the range of conditions chiropractors provide it for, and whether the benefit outweighs the extremely small chance of a serious complication.

This will help parents make an informed choice about health care for their child.

Matt Fernandez, Senior lecturer and researcher in chiropractic, CQUniversity Australia; Giovanni E. Ferreira, NHMRC Emerging Leader Research Fellow, Institute of Musculoskeletal Health, University of Sydney, and Joshua Zadro, NHMRC Emerging Leader Research Fellow, Sydney Musculoskeletal Health, University of Sydney

This article is republished from The Conversation under a Creative Commons license. Read the original article.

Toddler milk is popular and becoming more so. Just over a third of Australian toddlers drink it. Parents spend hundreds of millions of dollars on it globally. Around the world, toddler milk makes up nearly half of total formula milk sales, with a 200% growth since 2005. Growth is expected to continue.

We’re concerned about the growing popularity of toddler milk – about its nutritional content, cost, how it’s marketed, and about the impact on the health and feeding of young children. Some of us voiced our concerns on the ABC’s 7.30 program recently.

But what’s in toddler milk? How does it compare to cow’s milk? How did it become so popular?

What is toddler milk? Is it healthy?

Toddler milk is marketed as appropriate for children aged one to three years. This ultra-processed food contains:

• skim milk powder (cow, soy or goat)
• vegetable oil
• sugars (including added sugars)
• emulsifiers (to help bind the ingredients and improve the texture)

• added vitamins and minerals.

Toddler milk is usually lower in calcium and protein, and higher in sugar and calories than regular cow’s milk. Depending on the brand, a serve of toddler milk can contain as much sugar as a soft drink.

Even though toddler milks have added vitamins and minerals, these are found in and better absorbed from regular foods and breastmilk. Toddlers do not need the level of nutrients found in these products if they are eating a varied diet.

Global health authorities, including the World Health Organization (WHO), and Australia’s National Health and Medical Research Council, do not recommend toddler milk for healthy toddlers.

Some children with specific metabolic or dietary medical problems might need tailored alternatives to cow’s milk. However, these products generally are not toddler milks and would be a specific product prescribed by a health-care provider.

Toddler milk is also up to four to five times more expensive than regular cow’s milk. “Premium” toddler milk (the same product, with higher levels of vitamins and minerals) is more expensive.

With the cost-of-living crisis, this means families might choose to go without other essentials to afford toddler milk.

How toddler milk was invented

Toddler milk was created so infant formula companies could get around rules preventing them from advertising their infant formula.

When manufacturers claim benefits of their toddler milk, many parents assume these claimed benefits apply to infant formula (known as cross-promotion). In other words, marketing toddler milks also boosts interest in their infant formula.

Manufacturers also create brand loyalty and recognition by making the labels of their toddler milk look similar to their infant formula. For parents who used infant formula, toddler milk is positioned as the next stage in feeding.

How toddler milk became so popular

Toddler milk is heavily marketed. Parents are told toddler milk is healthy and provides extra nutrition. Marketing tells parents it will benefit their child’s growth and development, their brain function and their immune system.

Toddler milk is also presented as a solution to fussy eating, which is common in toddlers.

However, regularly drinking toddler milk could increase the risk of fussiness as it reduces opportunities for toddlers to try new foods. It’s also sweet, needs no chewing, and essentially displaces energy and nutrients that whole foods provide.

Growing concern

The WHO, along with public health academics, has been raising concerns about the marketing of toddler milk for years.

In Australia, moves to curb how toddler milk is promoted have gone nowhere. Toddler milk is in a category of foods that are allowed to be fortified (to have vitamins and minerals added), with no marketing restrictions. The Australian Competition & Consumer Commission also has concerns about the rise of toddler milk marketing. Despite this, there is no change in how it’s regulated.

This is in contrast to voluntary marketing restrictions in Australia for infant formula.

What needs to happen?

There is enough evidence to show the marketing of commercial milk formula, including toddler milk, influences parents and undermines child health.

So governments need to act to protect parents from this marketing, and to put child health over profits.

Public health authorities and advocates, including us, are calling for the restriction of marketing (not selling) of all formula products for infants and toddlers from birth through to age three years.

Ideally, this would be mandatory, government-enforced marketing restrictions as opposed to industry self-regulation in place currently for infant formulas.

We musn’t blame parents

Toddlers are eating more processed foods (including toddler milk) than ever because time-poor parents are seeking a convenient option to ensure their child is getting adequate nutrition.

Formula manufacturers have used this information, and created a demand for an unnecessary product.

Parents want to do the best for their toddlers, but they need to know the marketing behind toddler milks is misleading.

Toddler milk is an unnecessary, unhealthy, expensive product. Toddlers just need whole foods and breastmilk, and/or cow’s milk or a non-dairy, milk alternative.

If parents are worried about their child’s eating, they should see a health-care professional.

Anthea Rhodes, a paediatrician from Royal Children’s Hospital Melbourne and a lecturer at the University of Melbourne, co-authored this article.

Jennifer McCann, Lecturer Nutrition Sciences, Institute for Physical Activity and Nutrition, Deakin University; Karleen Gribble, Adjunct Associate Professor, School of Nursing and Midwifery, Western Sydney University, and Naomi Hull, PhD candidate, University of Sydney

This article is republished from The Conversation under a Creative Commons license. Read the original article.