Resolution of Suckling Intolerance
in a 6-month-old Chiropractic Patient

This section is compiled by Frank M. Painter, D.C.
Send all comments or additions to:   Frankp@chiro.org

FROM:   J Manipulative Physiol Ther 2000 (Nov); 23 (9): 615–618 ~ FULL TEXT

David P. Holtrop, DC, DICCP

4171 S. 15th Street,
Sheboygan, WI 53081

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OBJECTIVE:   To discuss the management and resolution of suckling intolerance in a 6-month-old infant.

CLINICAL FEATURES:   A 6-month-old boy with a 4(1/2)-month history of aversion to suckling was evaluated in a chiropractic office. Static and motion palpation and observation detected an abnormal inward dishing at the occipitoparietal junction, as well as upper cervical (C1-C2) asymmetry and fixation. These indicated the presence of cranial and upper cervical subluxations.

INTERVENTION AND OUTCOME:   The patient was treated 5 times through use of cranial adjusting; 4 of these visits included atlas (C1) adjustment. The suckling intolerance resolved immediately after the first office visit and did not return.

CONCLUSION:   It is possible that in the infant, a relationship between mechanical abnormalities of the cervicocranial junction and suckling dysfunction exists; further research in this area could be beneficial. Possible physiological etiologies of painful suckling are presented.

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From the Full-Text Article:

Introduction

The inability of an infant to inform his or her health practitioner of the nature of symptoms is a distinguishing feature of pediatric care. Chiropractic pediatric information in the indexed health care literature is to a large degree conspicuous by its absence. I prepared this case report because of that absence and because of the interesting and seemingly unusual nature of this case.

An infant with suckling intolerance was brought to a chiropractic office for evaluation, wherein upper cervical and cranial biomechanical aberrancies were detected. During a total of 5 office visits, gentle cranial and upper cervical adjustments were rendered; these were followed by resolution of palpable objective findings. The infant's problem resolved after his first office visit.

For the purposes of this article, the term cranial adjusting refers to light fingertip contacts or pressure to specific sites of the cranium, as originally taught by Upledger [1] and as currently taught by Phillips. [2] Also for the purpose of this article, the term subluxation refers to apparent misalignment of a bone relative to adjacent structures, as evidenced by asymmetry and joint fixation.

Chiropractors often use listings to denote the direction of subluxation relative to adjacent structures. The Gonstead chiropractic technique uses the listing ASR when the first cervical vertebra is laterally displaced to the right. I use the term anterior occiput to denote anterior dishing at the superior portion of the occipital bone. Chiropractic treatments used to reduce subluxation have been referred to as adjustments.

The internationally indexed scientific and medical literature appears to deal mostly with dental caries, infectious diseases, and genetic malformations when discussing suckling intolerance. In 1985, Forsyth et al [3] questioned the mothers of 189 breast-fed and 184 formula-fed infants and found that 35% of those in each group reported that their infants had moderate to severe problems with feeding or crying behavior.

The suckling reflex is normally present at birth, along with the ability to suck and swallow. It is a primitive reflex. Suckling has been found to induce feelings of calm, reduce heart and metabolic rates, and increase an infant's pain threshold. [4] Citations pertaining to the natural history of suckling intolerance could not be found.

A review of chiropractic publications indexed in Index Medicus (MEDLINE) or in the Index to Chiropractic Literature yielded no articles related to aversion to suckling. A review of the nonindexed chiropractic literature did reveal a small number of references to resolution of breast-feeding dysfunction on implementation of chiropractic care. In 1999, Hewitt [5] described 2 infants whose breast-feeding dysfunction resolved after 1-2 upper cervical and/or cranial adjustments. Vallone, [6] in 1997, reported on 2 infants whose breast-feeding difficulties improved after their first chiropractic treatment. Her article described a 4-month-old boy whose suckling difficulties resolved after 1 visit involving an upper neck (C1) adjustment combined with internal pterygoid trigger point therapy (pressure or fingertip massage), along with nursing counseling. She also described a 2-day-old whose suckling troubles disappeared after 5 cranial adjustment office visits. In 1988, Esch [7] reported on the immediate exhibition of the (previously absent) rooting reflex in a 2-day-old child after an atlas adjustment. At the International Chiropractic Association's 1993 national conference on chiropractic and pediatrics in Arlington, Va, Arcardi [8] reported on the perceived commonality of temporo-mandibular joint (TMJ) dysfunction and resulting breast-feeding difficulty, both apparently stemming from the effects of the birth process on the cranium. A wide variety of problems have been reported by Gutman [9] as potentially arising from subluxation or biomechanical dysfunction in the upper cervical spines of newborns.

The case described in this article is unique in that the suckling difficulty began 4 months after birth and was related to drinking from a bottle rather than to breast-feeding.

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Discussion

The term cervicocraniomandibular syndrome denotes the potential of the TMJ, cranial articulations, and upper cervical spine to influence one another. In the infant, the cranial bones are more mobile than in the adult and are separated by wide strips of cartilage; their relative positions shift during vaginal birth. The birthing process also involves lateral flexion, rotation, and traction to the upper cervical spine, along with a great deal of axial compression followed by distraction.

In a clinical setting, the causes of chiropractic problems are often suspected of having occurred before the onset of resultant symptoms. In the absence of postnatal trauma, I believe that cranial and upper cervical subluxation, resulting from mechanical factors of birth, did not self-correct and gradually worsened. Such subluxation could theoretically result in pain that could be exacerbated by suckling efforts.

The scientific literature seems to be drawing more and more links between the function of the upper cervical spine and head and headache pain. [10–12] Pain fibers of the trigeminal nerve originate from receptors in the scalp, skull, meninges, and vessel walls within the brain. Traction on these fibers produces pain. [13] If preexisting cranial subluxation would be worsened by suckling efforts, suckling probably could result in headache pain for an infant.

Coordination between perioral muscles and TMJ function has been found to be important for proper suckling, [14] and tongue action and jaw lowering play primary roles in producing good suckling strength. [15] Hypertonicity of TMJ-related muscles, such as the temporalis, could result in spasm and thus in painful headache when suckling was attempted. Alternatively, pain might stem from the TMJ itself when suckling is attempted if TMJ alignment and function have been impaired, perhaps as a result of upper cervical and/or cranial subluxation.

Pulek and Horwitz [16] proposed in 1973 that obstruction of the eustachian tube lymphatics might be the mechanism for the production of serous otitis media. Lymph is moved along as a result of proper muscle activity and motion, and muscle relaxation, along with improved range of motion, is generally an immediate effect of chiropractic adjusting. Adult patients often mention a decrease in sinus pressure after cervical adjusting, and Fysh [17] theorizes that improved lymphatic drainage from the head and neck may explain alleviation of middle ear infection after chiropractic care. Perhaps congestion of sinuses and/or the middle ear could produce pain similar to that associated with flying and scuba diving—pain that could be exacerbated by the intraoral pressure changes of suckling.

Upledger [1] suggested that the hypoglossal nerve may be irritated by cranial subluxation. The nerve exits just lateral to the occipital condyles, in close proximity to the occipital bone and the atlantooccipital joint capsule. If such subluxation resulted in hypoglossal nerve dysfunction, impaired tongue function could lead to frustration on the part of an infant attempting to suckle.

This case report has some inherent weaknesses. By definition, it is not a report on a controlled study and has no statistical significance. Furthermore, the patient's condition may have coincidentally self-resolved at the time of the onset of chiropractic care. Therefore, a causal relationship cannot be drawn between the treatment rendered and the favorable outcome of the case. However, such a causal relationship was suspected by the patient's parents as well as by me, and chiropractic adjusting appears to have been effective in this case.

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Conclusion

Chiropractic care of the infant is a topic that is in need of exploration in the scientific literature. Future case series and randomized comparative group clinical trials, as well as research comparing the outcomes of upper cervical and cranial adjusting, could shed valuable light on the appropriate role(s) of the chiropractor in managing certain neonatal feeding dysfunction cases.

In this case, a 6–month-old male infant had reportedly experienced significant discomfort while attempting to drink from a bottle over a period of 2 months. He drank freely and without fussing after the first of 5 chiropractic visits, which consisted of C1 and cranial adjusting.

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References:

1. Upledger, J.
   Craniosacral therapy. :
   Eastland Press, Seattle; 1983

2. Phillips, CF.
   Craniosacral therapy.
   in: Pediatric chiropractic. :
   Williams & Wilkins, Baltimore; 1998

3. Forsyth, B, Leventhal, J, and McCarthy, P.
   Mothers' perceptions of problems of feeding and crying behaviors: a prospective study.
   Am J Dis Child. 1985; 139: 269–272

4. Blass, E.
   Behavioral and physiological consequences of suckling in rat and human newborns.
   Acta Paediatr Suppl. 1994; 397: 71–76

5. Hewitt, E.
   Chiropractic care for infants with dysfunctional nursing: a case series.
   J Clin Chiropr Pediatr. 1999; 4: 241–244

6. Vallone, S.
   Linking craniocervical subluxation in infants with breast-feeding difficulties.
   Intl Rev Chiropr. 1997; 53: 43–48

7. Esch, S.
   Case reports in chiropractic pediatrics.
   ACA J Chiropr. 1988; 12: 26–33

8. Arcardi, V.
   Birth induced temporomandibular dysfunction: the most common cause of breast-feeding difficulties.
   (Arlington, Va)
   in: Proceedings of the National Conference on Chiropractic and Pediatrics.
   International Chiropractors Association, ; 1993 Oct 1-3

9. Gutman, G.
   Blocked atlantal nerve syndrome in babies and infants.
   Manuelle Med. 1987; 25: 5–10

10. Mitchell, B, Humphreys, B, and O'Sullivan, E.
    Attachments of the ligamentum nuchae to cervical posterior spinal dura and the lateral part of the occipital bone.
    J Manipulative Physiol Ther. 1998; 21: 145–148

11. Sessle, B.
    Neurophysiological mechanisms related to craniofacial and cervical pain.
    Topics In Clinical Chiropractic. 1998; 5: 36–38

12. Wight, S, Osborne, N, and Breen, A.
    Incidence of ponticulus posterior of the atlas in migraine and cervicogenic headache.
    J Manipulative Physiol Ther. 1999; 22: 15–20

13. Huff, K.
    Headaches.
    in: Pediatrics: a primary care approach. :
    WB Saunders, Philadelphia; 1996: 374

14. Tamura, Y, Horikawa, Y, and Yoshida, S.
    Coordination of tongue movements and perioral muscle activities during nutritive suckling.
    Dev Med Child Neurol. 1996; 38: 503–510

15. Tamura, Y, Matsushita, S, Shinoda, K, and Yoshida, S.
    Development of perioral muscle activity during suckling in infants: a cross-sectional and follow-up study.
    Dev Med Child Neurol. 1998; 40: 344–348

16. Pulek, J and Horwitz, M.
    Diseases of the eustachian tube.
    in: Otolaryngology. :
    WB Saunders, Philadelphia; 1972: 275–292

17. Fysh, P.
    Chronic recurrent otitis media: case series of five patients with recommendations for case management.
    J Clin Chiropr Pediatr. 1996; 1: 66–78

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