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Chiropractic Journal of Australia : CJA September 2012
102 Chiropractic Journal of Australia Volume 42 Number 3 September 2012 Two questions related to an infant’s suck. The frst related to general suck ability and the second to suck type. Thus the results for these two questions differed slightly, and there was some contradiction with some rating poor suck ability, but describing a normal suck type. The questions have been modifed to address these contradictions (see appendix, modifed questionnaire). The ability to swallow is controlled by cranial nerves v, ix and x. There were improvements in reported swallow ability in 14/16 infants, however most of these improvements were mild only. Finally, there were improvements in reported pain when feeding, overall attachment, overall comfort and stress whilst feeding. In regards to stress, 15/16 rated improvements of which 11 were signifcant. Maternal factors (such as perceived stress) are major reasons that mothers stop feeding. Thus correcting an infant factor (subluxation), can reduce maternal factors such as stress and pain, which may further affect other maternal factors such as let down, milk supply and blocked ducts/mastitis. The most common vertebral subluxation patterns that result in diffcult feeding are upper cervical subluxations (occiput and atlas), shoulder subluxations, sacral, elbow and wrist subluxations. Again, these results coincide with the typical expectations we see in practice. It seems obvious that an upper cervical/shoulder dysfunction is more likely to affect the breastfeeding process than a thoracic, lumbosacral or lower extremity subluxation. The neural physiology involved may vary however, possibly involving pain pathways, brain stem, or cranial nerve pathways. The link between specifc subluxation patterns and specifc breastfeeding behaviour was not clearly demonstrated, due to the relatively small sample size, and the structure of the questionnaire. In addition, some patients had more than one subluxation which made linking a particular behaviour to either subluxation diffcult. Having said this, there were tendencies that indicate certain patterns. Clinically, it has been observed that specifc patterns of subluxation affect specifc breastfeeding behaviours. Upper cervical subluxations tend to affect attachment. Arching may be associated with the AS occiput subluxation. This subluxation pattern is associated with pain on cervical fexion, which is required for attachment, and therefore the infant may respond with extension of the neck, creating fexion/ extension fussiness, or an “arching pattern.” Side to side shaking is often associated with the atlas subluxation pattern. Due to the atlas’ role in cervical rotation, dysfunction may be associated with rotational fussiness which manifests as side to side shaking. The occiput subluxation was most linked to poor attachment and arching/extension movements once attached. The atlas subluxation correlated less with arching, as expected. The C1 subluxation could not be defnitively linked to shaking, due to a small number of atlas subluxations in the study. A larger number would detect more C1 subluxations and thus clarify whether a defnite link with shaking is present. It has been observed clinically that the side of subluxation (e.g. right atlas, occiput or shoulder) may be associated with discomfort on that side. For example, a right sided subluxation may cause discomfort on the left breast when in the cradle hold position, thus creating a preference for the other side. There was a 59% correlation between the side of subluxation and the side of breastfeeding diffculty, with 4 cases unclear due to bilateral subluxations (for example concurrent right shoulder/left neck). Upper cervical joint dysfunction of any type (C0-C3) may affect brainstem neural processes, and thus affect the cranial nerves involved in sucking, rooting and swallowing. Upper cervical spine dysfunction may affect the ability to suck (cranial nerves 5, 7, 12), and swallow (cranial nerves 9, 10). These are usually reported as poor use of lips and tongue (suck), and frequent choking, gagging, and coughing (swallow). The parent, maternal child health nurse, or lactation consultant may attribute this dysfunction to a fast let down. A defnitive correlation between upper cervical subluxation and suck grading, suck type or swallow ability was not evident in this study, again due to small sample size and multiple subluxations. However, it is clear in the results that subluxation does affect the quality and type of suck, and the severity of choking, gagging and cough when feeding, and that there are improvements in these areas after correction. Clinical observation has identifed major subluxation patterns and associated physical effects. Temporomandibular joint (TMJ) dysfunction is usually (but not always) compensatory to upper cervical joint subluxation (especially occiput). Any other area of the spine or extremity can also be involved, however these are less common and cause less specifc patterns. Cranial dysfunction was not examined in this study. The diffculty with multiple subluxations can be addressed in a further study by either excluding those with multiple subluxations, or adjusting only one subluxation until function is normal, then correcting the others sequentially. Outcomes need to be constantly monitored. Future questionnaires need to be less detailed, and a number of the questions used in this pilot study were unnecessary, and have been eliminated. The analysing of raw data and resultant statistical signifcance of the results may be better performed by a trained researcher with skills in research or statistical analysis. Finally, a future study would need to include a cohort of at least 100-150 patients. Table 8: Swallow Poor swallow Occiput Atlas GHJ Combo Normal: 1 0/16 0/1 0/1 1/1 Mild: 15 5/15 1/15 0/15 9/15 Severe: 3 1/3 0/3 0/3 2/3 CHIROPRACTIC AND BREASTFEEDING PROBLEMS STEWART
CJA June 2012
CJA December 2012