Severe head lag, neck hypotonia
A four week old male infant came in with his mother sent to us by a lactation consultant at a local hospital for latch issues. Mother described purpose of the visit was for “neck issues” to be explored, and for resolving a traumatic birth injury. The birth was ten days late and he was posteriorly positioned in-utero, and OB induced mother into labor. She labored for forty hours with little progress and some pushing. There were some decels on the fetal monitor so an emergency cesarean was performed. He was born with a swollen and bruised face. His head size was at the upper (100) percentile. Hydrocephalus was suspected. Neurosurgeons tried to prepare the mother that the head lag was likely due to brain damage. A neck and head CT was performed. Results were negative for brain damage. No infarct in-utero had happened. Pediatricians were unable to explain the head lag. A “wait and see” attitude was adopted by the primary pediatrician however they were very guarded about his development.
Infant presented on exam with unequal coronal sutures, 3-1/2 cm larger on right. While lying supine the infant was arching the entire spine off the table. The left leg was contracted 1 inch, large nodule palpable at C2 on the left and unequal skin folds around neck when viewed A-P supine. There was an unusual amount of extra skin on the anterior neck and the thyroid cartilage appeared much more prominent than that of other infants his age. Atlas posterior arch was prominent on the left. Right head tilt noted. When lifted by arms off the table from a supine position, the head markedly lagged behind. Mother had to use a nipple shield for a very “loose and sloppy suck”. Nail beds were purple and not pink, arms and hands were mottled. Normally in very pale infants mottling of the skin is somewhat normal. There was marked mottling of the skin.
Cervical spine X-rays were exposed including lateral, vertex/horizontal and nasium/frontal views. Atlas plane line was high on the right 12mm, with an atlas rotated 3 degrees anteriorly. Anteriorlisthesis of C5 was noted on the lateral. The adjustment was made with his right side up, stabilized by mother and by another upper cervical colleague who stabilized the head in neutral to avoid head extension during the adjustment. Immediately after the adjustment the infant lifted his head for the first time and the head lag appeared to be gone. Leg length evened. He breast fed well that day. Nail-beds were pink immediately after the adjustment. He was seen two days later and evaluated for an atlas subluxation. His upper cervical spine was ‘holding’. His adjustment stayed in place at visits one week later and two weeks later. His arching diminished. He was then checked monthly for 3 months. At the 3 month visit he was negative for an atlas subluxation and met all developmental milestones. He was seen for further craniosacral therapy to deal with remaining head asymmetry and birth trauma.
3 month old with developmental delays
A grandfather brought his grandson (with parental permission) for evaluation of developmental delays. Parents were present but stayed more in the background. Grandfather’s occupation is a speech pathologist. History: Cesarean due to questionable ‘small’ vaginal canal and uterus per OB. It was reported that his shoulder was “stuck” during delivery making a vaginal delivery impossible. This 3 month old was unable to track objects or faces. It was reported that his suck was weak, hearing acuity appeared weak and he had general stiffness of the trunk and arms. His use of his right arm was markedly more limited than left.
Mother had to pump breast milk due to inefficient suck initially after birth. At exam the infant had a right contracted leg 1 and ½ inches, circumoral cyanosis, mottled skin, cold arms and legs, a prominent posterior arch with pea sized nodule by C2 done seated. Para spinal musculature was hypertonic at left upper dorsal longissimus group. Palpation of the TMJ revealed large knotted nodule on right masseter muscle. Figure 31.38 shows innervation of glossopharyngeal nerve to masseter muscle. Note close proximity of C1 vertebrae and its ganglion of nerves. Right atlas challenge temporarily evened short right leg, relaxed masseter muscle and temporarily relaxed paraspinal musculature.
The right occiput was flattened and he had a left sacral rotation. The right arm had diminished movement.
Parental agreement was obtained to adjust infant with portable Atlas Orthogonal Precision Adjusting Instrument. X-rays were not obtained at this time due to lack of parental consent. The patient was placed on his uninvolved side, head neutral, stabilized by mother and grandfather at the head. The right transverse process was contacted with styloid and a compressional wave was released from the trigger. After the infant was placed seated, he immediately displayed tracking objects for his parents, his color improved in his arms and legs and the circumoral cyanosis was about 80% gone. Leg length was equal.
The following week his sacrum was still rotated. He was free of cyanosis and there was no prominence of the posterior arch of atlas. Craniosacral therapy was initiated and was done weekly for 2 weeks. Two months later the Grandparents brought the boy in for evaluation. Parents allowed this visit but felt he would ‘grow out’ of any of the remaining problems. The patient had decreased circulation in extremities, and the neck had tightened. No palpable nodules at C1 or C2, but paraspinals were hypertonic again at the upper left dorsal longissimus group. Leg was ½ inch short. Another atlas correction was made utilizing the same listing as was made initially. The right shoulder was found to be subluxated and another approach was used to correct this. After the adjustment, paraspinal muscles were more symmetrical in tone, hands and feet became pink and the mottled appearance of skin was gone. Leg length evened.
Response was a general relaxation of neck muscles and upper dorsal paraspinals. Craniosacral therapy was done weekly for a month with upper cervical evaluations. Then the schedule lessened to once a month. He has been evaluated and adjusted if needed monthly since that time. In the past six months he has had an upper cervical correction three times with other modalities used on a talus subluxation of the right foot, right ribcage and right humerus.
Most upper cervical pediatric patients are evaluated every 3-4 months once the initial acute stabilization and correction period is over. This schedule usually follows developmental milestones. However, parents are encouraged to bring their children in monthly for better spinal health.
Severe reflux, eczema in a 5 month old
A male child was brought in by his mother because of a new problem of spitting up. He was delivered by caesarean, mother was told her pelvis is platypelloid. This pelvis type often has labor ending in C-section. (11) At birth he had difficulty breastfeeding but that was no longer the case. Mother stated her son would awaken every two hours from spitting up. During the day the spit up was 3-4 times per hour. Figure 31.39 shows the location and innervation lower in the GI tract of the Vagus Nerve. The vomit was not projectile. On exam he had decreased left head rotation, favored right neck rotation, gluteal fold curved to the left, even gluteal creases. Left atlas challenge supine check evened right short leg. His left eyelid appeared lower than the right. A nodule was present at C1 and C2 on the right with heat palpable, and a left sacral rotation was seen. Eczema was present in all the skin folds and back of neck. This is a usual location of eczema in infancy and childhood. (11) The occiput was visibly larger on the left than the right and suboccipital muscles were hypertonic on the left. Radiographs were obtained. A lateral cervical X-ray showed an anteriorly displaced atlas (anterior of the odontoid line) and posterior arch of atlas was ‘jammed’ up under the occiput. Infants with this presentation on the lateral radiograph often have a history of seizures. This boy did not have seizures. The atlas frontal plane line was high on the right measuring 10 millimeters, with lower cervical spine contralateral. The y axis showed rotation of 1 degree anterior on the right. He was adjusted with the involved side up with the portable atlas orthogonal precision adjusting instrument. Mother and colleague stabilized body and head while the adjustment was made. Right short leg evened. No apparent other change was noted. Mother traveled for two weeks immediately after the adjustment. Two days later the mother reported slight worsening of the spit up and then two days later it stopped altogether. At the next visit there was a report of only rare spit ups and only small amounts. A post lateral view was done as well as Nasium and Vertex views. The atlas was no longer in an aberrant position. The posterior arch had space between it and the occiput. The high atlas on the right was now level and there was still .25 degrees on the y axis. Posteriority of the occiput resolved after the first atlas adjustment. This child had what appeared to be a left posterior inferior illium. Upon closer inspection, the pubic ramus on the anterior of the body was low on the left. A diagnosis of pelvic shearing from the birth was possible. The pubic bone would even out if the atlas was corrected and this appeared to correct the distortion in the illium. Despite using a pediatric modified drop piece on the illium, with a superior to anterior cavitation with the child in a prone position, it would not correct if the neck was unbalanced.
He was evaluated weekly for one month, then monthly for 2 months and required an atlas adjustment each time. Evaluation at every three months and no upper cervical spine subluxation was present. When he started to walk at one year, his left foot was ‘toeing out’ and other chiropractic programs were initiated after the upper cervical spine was evaluated. His eczema was non-existent as long as his upper cervical spine was clear of subluxation.
11 year old with learning difficulties
A female patient was brought in by her mother for craniosacral therapy. School work seemed difficult to her and she required extra tutors. She always had a very small appetite reported since birth. She was referred by her birth assistant (doula). Her history involved a traumatic vaginal delivery born at 35 weeks gestation after the mother had suffered some kind of emotional trauma. The baby was only admitted to the NICU for four days. As a 2 year old she had a chronic cough. She wore glasses and was an avid swimmer and played volleyball. On exam she was found to have upper motor neuron testing differences. She had a surprising positive Romberg’s test off balance to the right almost falling over. Because of her learning difficulty she had already seen a neurologist so at this time it was not prudent to refer her to one because of the positive Romberg’s test. It was difficult for her to toe walk on the left side. Her heel to toe walk was very unbalanced and hand slap was markedly uncoordinated on the left. On the finger to nose test, the left hand was far off target. Postural analysis: she had a habit of slumping when seated with a right high shoulder and hip. Palpation of C1 found tender nodule on left and at C2 left nodule. C4 and C5 had tenderness at the articular pillars. Her right leg inequality was a half an inch. Vibration sense was diminished in the left medial malleoli. Cranial nerve VIII testing: Weber and Rinne tests were abnormal. Referral was made for Audiology. Three radiographs were taken of the cervical spine. The lateral showed greatly diminished space between C1 and C2. They did not appear to be fused congenitally. The Frontal X-ray showed atlas high on the right up 4mm, and the lower cervical spine ipsilateral to the upper angle. This is an atypical listing. The Vertex had the greatest degree of subluxation with 6 degrees of rotation posterior on the right. She was adjusted with involved side up on a high head piece with her shoulder pulled posteriorly 1 ½ inches to help move C2 which was 15 degrees to the left of center. Post films were taken 2 days later and on the nasium X-ray all angles had decreased by half. The vertex showed 2 degrees of rotation remaining. She was found to have no tender nodules and legs were even. She was able to heel/toe walk without difficulty. Her toe walk improved and finger to nose was now accurate. Romberg’s test was now negative. She ‘held’ her first adjustment for 2 weeks then required another correction. Mother reported a marked increase in the child’s appetite. She then was seen monthly and ‘held’ for 2 months and required another correction. She was seen monthly for one more year and required 4 more corrections during that time. It was reported that her school work was better and she was able to focus and get her work done without help. She did receive craniosacral therapy concurrent with the first 4 weeks of care. It is this author’s opinion to always provide the service which the patient asks for initially as long as it is not contraindicated with the current program of care.
Severe reflux and Nipple Aversion in a 11 week old
A mother did research on the internet for information on reflux and found a case study of an infant whose reflux was resolved with Chiropractic adjustments published in a prominent medical journal. Her 11 week old infant had been born by Cesarean due to a breech presentation and had severe reflux at week 6 of life. A milk allergy was suspected. He also had constipation and would not have a bowel movement for 4 days at a time.
Exam findings: appearance of head, very misshapen and large with flattened parietals on one side and opposite side flattened frontal bone. Abdomen distended with gas. Mild temperament. Cries soon after breast feeding and arches spine. He appears to be in pain after breast milk.
He has an aversion to the nipple during painful episodes after eating.
Spinal exam: Webster’s coronal suture measurement 1 and ½ cm difference side to side.
There were findings of C1 and C2 palpable nodules, posterior occiput on left, and a right contracted leg one inch. Right paraspinal muscles longissimus group 3+ hypertonic on a 1-3 scale. A TP challenge of C1 on right evened the right leg.
X-ray findings: High lateral right atlas subluxation, with a plane line of 7mm and a 6 degree y-axis rotation posterior. Treatment: Infant was placed on his left side stabilized by mother and the Atlas Orthogonal hand held precision adjusting instrument delivered the adjustment with the proper rotation to clear the listing. Immediate post Xrays were done which confirmed atlas plane line now was zero, and one degree remained on the y axis film.
Infant was seen the next day and the mother reported a 50% reduction in reflux with more comfortable rest periods between feedings and some nipple aversion still present.
He presented with a ¼ inch short leg and minimal paraspinal hypertonicity. He was not re-adjusted at that time. One week later the right neck musculature was hypertonic compared to left and the leg had shortened by a half inch. Right paraspinal longissimus group was more hypertonic than left. Decision made to re-adjust using original listing from X-rays. Response was a reduction of all the findings and general relaxation observable. Mother reported stools every 2 days instead of four days.
He had 2 more visits one week apart and appeared to be making progress as the reflux episodes were decreasing. Each visit he required an additional atlas adjustment. He was concurrently being worked up by GI specialist because blood was found in his stool.
Premature infant with Colic
A baby born 6 weeks early came to our office for colic symptoms. Mother reported between 4pm and 8pm constant crying which was inconsolable. Pregnancy history was unremarkable for adverse events which could have precipitated a premature delivery.
Infant was 5 weeks old adjusted age. She spent 4 weeks in the NICU. She was given antibiotics during her hospital stay.
Mother reported right head preference asleep and during the day if upright in car seat. Infant had sensitivity to noise and light and would become overwhelmed if stimulated more than 5 minutes at a time. This is a common finding in graduates of an NICU.
Infant had to sleep on her stomach with her head turned to either side or she would not sleep at all.
Exam: Premature head molding with very flattened temporal bones and high parietal bones; resembling a toaster. This is due to positioning in the NICU. Her eyes were somewhat exopthalmic. Abdomen was obviously distended with gas. Frequent expelling of gas noted. Due to gas pressure and a week bowel wall, an umbilical hernia was present. Right paraspinal musculature 3+ hypertonicity was noted. Contracted left leg one inch noted with a subluxated illium posterior and inferior on the left. Left leg lengthened temporarily with straight lateral pressure test (atlas challenge) of C1 TP on left. Visits were 2 x’s per week and a modified upper cervical adjustment was made the first week twice on the left which abated symptoms for 2 days at a time but left the parent frustrated that it wasn’t permanent. Decision was made by the family to have upper cervical X-rays taken of the infant. Xrays revealed a atlas plane line of 2mm on the left with a one degree posterior Y axis rotation of C1 on the Vertex.
Adjustment was made on the Atlas Orthogonal standing table with the patient on her right side, stabilized by the mother. Leg length evened and infant smiled for the first time. She was seen one week later and was “holding” the adjustment. Mother reported only mild fussiness at “her bewitching hour”. She was seen one more week then 3 weeks later had to be adjusted again. This time head preference to the right was corrected. At 12 weeks corrected age, she was completely free of any fussiness and was concentrating on growing. She is being evaluated monthly for upper cervical care.
Reference:
- Anrig and Plaugher, Pediatric Chiropractic, first edition, Lippincott Williams & Wilkins, first edition, 1998
