International peer-reviewed chiropractic pediatric history and examination forms for the infant, child, and adolescent

Sue A. Weber BSc, DC, MScAPP (Pediatric musculoskeletal health)
Chairperson/faculty European Academy Chiropractic special interest group in pediatrics (FEAC)
Faculty Royal College of Chiropractors Pediatrics (FRCC)
Practitioner, Stockholm Sweden
dr.sue@telia.com

ABSTRACT
The assessment of the pediatric patient is a specialized area of chiropractic practice, requiring additional knowledge and skills. In recognition of this, European Academy of Chiropractors’ special interest group for pediatrics together with an international group of pediatric musculoskeletal experts have expanded on the previously published basic history and examination forms for infants, children and adolescents. The aim of these forms is to further assist the chiropractor in identifying red flags and differentially diagnosing problems in musculoskeletal and mental health as they present throughout growth and development. The process of development of the forms is outlined, and the three forms are presented in this article.

Key Words: chiropractic pediatric, pediatric history form, pediatric examination form, pediatric red flags, pediatric musculoskeletal health.

Introduction
Chiropractic education typically includes a cursory level of education within pediatrics¹ which varies from institution to institution. Practitioners interested in pediatrics can pursue additional education through continuing professional development courses, a diplomate, a Master’s degree or a PhD through a range of providers. Surveys show that the majority of practitioners see children of all ages but feel they have inadequate skills in assessment and treatment.¹

Triaging musculoskeletal and non-musculoskeletal complaints is of the highest priority for the chiropractor.² This is a vital skill and knowledge base for those seeing the pediatric patients to develop, as differential diagnosis and treatment are significantly different than in the adult patient.³ Children, and particularly infants, are not miniature adults. There are specific and different concerns for each age group which must be addressed with an appropriate history and examination. Basic forms for the infant, child and adolescent have been published to establish a minimum competency for chiropractors who lack advanced education in this area.⁴ These forms address skills specifically in musculoskeletal differential diagnosis as well as recognizing for referral the ill child ensuring safe care of this population. Additional exam forms addressing specific pediatric complaints commonly presenting to chiropractors were initiated and intended to complement the basic forms. As these were being drawn up there seemed to be unnecessary repetition so this idea was abandoned. More comprehensive history and exam forms were deemed more appropriate and are presented in this article. They address more age-specific issues in musculoskeletal health, sensory issues, and psychosocial health. For the purposes of safety, the forms include a review of systems, a neurological examination, and red flags. The infant forms include, besides history, a review of the mothers’ health and the perinatal period.

AIMS
The European Academy of Chiropractic (EAC) is working to provide cost-free postgraduate education for practitioners. One of the EAC special interest groups (SIG) is pediatrics, where members are working to advance education specific to pediatric practice. The SIG team in pediatrics published in 2021 basic history and exam forms for the infant, child and adolescent.⁴ The work since publication of these forms has been to draw up regional forms covering specific conditions within pediatric musculoskeletal health. Due to unnecessary repetition, we decided to enhance and expand the original forms to include these areas along with mental health and wellbeing in the different age groups. Psychosocial health was deemed important as is has become such burden for some children with an increased risk for suicide in adolescents. Pediatric headache history, exam and questionnaire have been recently published separately,⁵ so this will be referenced for use in the comprehensive form. An outcome assessment for suboptimal breastfeeding with a musculoskeletal origin has been published recently⁶ and is referred to in these forms. Malignancies in children, though rare are different than those presenting in adults.⁷Clinicians should remain abreast of current prevalence statistics and include in the differential diagnosis when appropriate. They are listed in Table 1.

The SIG team engaged the participation of several other chiropractors, most with advanced academic education within pediatrics (Masters or PhD) to review these forms. We intentionally invited practitioners from several different countries to participate to make this an international peer-reviewed pediatric project. A long-term goal is to have these forms implemented internationally to be able to collect data for use in future research projects. The forms are also intended for use as an outline for an academic musculoskeletal pediatric post-graduate education.

The three forms presented with this article are more comprehensive than those published in 2021.⁴ They have been designed to organize the pediatric history and examination, giving it consistency, aiding the practitioner in undertaking a thorough assessment. The age groups have been changed to reflect that the period of infancy and toddlerhood were better suited together (0-2 years) than toddler with the young child (Table 2).^6,8,9,10

The second group is two years to six years, the young child (Table 3)^5,9,10 and the third is 6-16 years which covers the child and the adolescent (Table 4).^5,9,10 The primary focus of the forms is on triaging common MSK and non-MSK presentations in the three pediatric age groups, and on identifying red flags for referral.^12-15 In highlighting non-MSK and red flag presentations, there is an emphasis on safety, particularly identifying and referring the ill child for medical assessment and care.

These forms are intended to address musculoskeletal problems which typically present during the different stages of growth and development. These forms also address more thoroughly issues of mental health, sensory issues, and neurodevelopment in all age groups. They may be helpful not only in reaching the correct diagnosis or diagnoses in order that proper management can be recommended in a timely manner, but that children who need co-management are recognized early in the process.

Process
The pediatric history, examination and red flag forms have been reviewed by 24 different chiropractors, representing 10 different countries: Australia, Belgium, Canada, Cyprus, Denmark, Germany, Malaysia, Norway, South Africa, Sweden, Switzerland, the UK and the United States. The UK was over-represented with nine chiropractors participating. Six participants have a DC degree of which two have a diplomate, fifteen of the participants have MSc in advanced pediatric musculoskeletal health, and three have a PhD with focus in pediatrics. Twenty-three participants work clinically with patients, two of which have graduated less than five years ago.

This process started on December 13, 2022. Thirty-two chiropractors were contacted of which eight chiropractors either did not respond or did not want to participate. One of these chiropractors had a conflict of interest as she is preparing pediatric history and exam forms for financial gain. Emails, tele-conferences, and telephone calls have been made monthly since then to ask for participation, to disperse and discuss each of the forms and to remind participants about the forms. Twenty- three participants who agreed to evaluate the forms reviewed and commented on all three forms, one participant commented on just the child form. Changes were made based on comments and the final iteration was then shared with educators within the field for their final comments. Recent graduates were asked to review the final forms for their completeness and practicality. All participants were asked for their permission to publish their names with educational degrees or diplomate.

Recommendations for chiropractors
It is recommended that chiropractors and other practitioners using manual therapy who are working with pediatrics regardless of their specialty education review these comprehensive forms to enhance their skills. Those without advanced education in pediatrics are encouraged to adopt these more comprehensive forms for clinical practice. Due to the comprehensive nature of the forms, it is understood that the practitioner should focus on the area of complaint and get more detailed information in areas that are problematic. The infant form differs in that it guides the practitioner through a detailed history before the primary complaint. The information gathered gives more clues to the origin of the problem and direction for the exam. Although the forms may be a bit cumbersome for the seasoned practitioner, they guide the newer and less experienced practitioners through a thorough process. These forms address psychosocial health, sensory and neurodevelopmental issues which may be new for the more experienced chiropractor and serve as a good reference in this area. Just as these forms reflect the fact that the child is growing and developing, treatment is also adjusted based on age and development.

A series of recorded lectures to accompany these forms are in progress, discussing key aspects of the history and examination of the pediatric patient. These will be soon available through the European Chiropractic Union home page, European Academy of Chiropractic (EAC) and the EAC Academy.

Conclusion
These forms represent a more comprehensive musculoskeletal assessment of pediatric patients from infancy through adolescence with a goal to ensure safe and effective management. The implementation of these forms should not only raise competence of practitioners, but with widespread use, enable data collection on a large scale for future research. The forms are also to serve as an outline for a postgraduate pediatric education in musculoskeletal health. The work to provide these clinical exam forms is to elevate the safety and quality of care provided by chiropractors to infants, children, and their families.

Limitations
The age groups presented cover more than one area of development. Ideally the pediatric forms should be more specific to distinctive periods of growth and development. Future work in this area would be to further breakdown the age groups and have forms for the neonate, infant, preschooler, child, pre-adolescent, and adolescent.

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