Medical Errors Kill, But Let’s Attack Chiropractors - Response to the flawed critique of pediatric chiropractic care by Misra et al and the double standards of conventional medicine

Originally published: 2025-01-07

When it comes to unfounded criticism of pediatric chiropractic care the paper titled: Chiropractic Care in Children: A Review of Evidence and Safety by Sanghamitra M. Misra, MD, MEd, Omar Jaber, MD, MPH, and Caroline Long, DC published December 22, 2024 in the journal Clinical Pediatrics takes the cake.

Misra and Jaber, accompanied by Long, a token chiropractor, present a highly biased and ignorant critique that relies on misleading claims and selective evidence. Hopefully its bias and ignorance and not intentional deception on their part. While they dismiss chiropractic care as lacking evidence, they fail to acknowledge its salutogenic foundation, which focuses on promoting health and optimizing nervous system function rather than treating specific diseases. At the same time, they turn a blind eye to glaring issues in conventional pediatric medicine, such as the rampant overprescription of antibiotics and the staggering rates of medical and medication errors, which harm millions of children annually.

If Misra want to compare body bags - we are ready.

In this article, we’ll dissect the flaws in their arguments, highlight the safety and efficacy of chiropractic care, and expose the selective scrutiny that undermines informed, patient-centered decision-making.

The following is a critique of their paper.

Introduction

The paper by Misra et al. critiques pediatric chiropractic care, presenting claims that are not only misleading but also demonstrative of a clear bias against complementary health practices. By employing vague language, selectively citing evidence, and ignoring broader research models, the authors undermine their credibility while presenting a contrived narrative. This response addresses their key assertions and highlights the flaws in their arguments.

Safety of Pediatric Chiropractic Care

Malpractice insurance data provides a striking contrast to Misra et al.’s implications regarding the risks of pediatric chiropractic care. Chiropractic malpractice premiums are among the lowest in healthcare, ranging from a few hundred to a couple thousand dollars annually—a fraction of the tens of thousands paid by pediatricians. This discrepancy underscores the safety record of chiropractic care. Despite tens of millions of annual pediatric chiropractic visits, malpractice insurers are unaware of actuarial data indicating increased risks associated with visits to chiropractors.

In contrast, medical errors are the third leading cause of death in the United States, highlighting the risks inherent in conventional medical care.

Dangers of Medical Pediatric Care

According to Johns Hopkins there are an estimated 250,000 deaths per year in the United States due to medical error.

It is essential to address the disproportionate scrutiny placed on chiropractic care compared to the risks inherent in conventional pediatric medicine. Medication errors in pediatrics are a significant concern, with an estimated 7.5 million preventable errors occurring annually among pediatric patients in the United States. Alarmingly, 14–31% of these errors result in harm or death. Pediatric patients face a 31% higher rate of medication errors compared to adults, as reported by the US Pharmacopeia Medication Errors Reporting Program. Errors in children’s medication orders, including prescribing, dispensing, and administering, occur in 5–27% of cases. Within inpatient settings, 22% of preventable medication errors could have been identified earlier or mitigated more effectively. Pediatric Intensive Care Units (PICUs) experience between 22 and 59 errors per 1,000 doses—seven times more frequent than in other pediatric inpatient units. Similarly, neonatal wards report error rates eight times higher than adult wards, with 13–91 errors per 100 admissions in Neonatal Intensive Care Units (NICUs), and preterm neonates face a disproportionate burden of errors, with an incidence rate of 75.4% compared to 24.6% in term neonates.

In specialized settings, 60% of anesthesiologists reported pediatric medication errors at least once annually, and 15% experienced such errors monthly. Emergency care presents additional risks, with 10–31% of medication errors resulting from issues like calculation mistakes, dose duplication, or wrong drug selection. Off-label drug use is a significant contributor to errors, accounting for 18–64% of cases in pediatric inpatient settings, and unlicensed drugs are associated with 7–10% of errors. Intravenous drug use also contributes to a high rate of errors, underscoring the complexity and risks involved in pediatric pharmacological care.

Otitis Media as an Example

Misra et al contend that there is insufficient evidence to recommend chiropractic care for children suffering from otitis media, meanwhile pediatricians ignore national guidelines regarding antibiotic use with over 90% of children in this age group being prescribed inappropriate courses, leading to substantial unnecessary antibiotic exposure. It is estimated that more than 40% of all antibiotic-days prescribed for AOM are unnecessary, which may harm children by causing adverse drug events (ADE), selecting for antibiotic-resistant bacteria, and increasing the risk of Clostridioides difficile infection. Additionally, antibiotic exposure is associated with the development of chronic diseases later in life. This juxtaposition highlights the hypocrisy in dismissing chiropractic care for children with OM due to limited evidence while the medical community continues to engage in widespread overprescription of antibiotics, despite clear guidelines and known harms. Such systemic issues are absent from Misra et al.'s analysis, exposing their selective bias.

Birth Trauma as Another Example of the Hypocrisy

Birth trauma, a significant yet often under-discussed issue, has far-reaching consequences for families and the healthcare system in the United States and around the world. Its incidence, prevalence, and economic costs is crucial to addressing this silent burden. Furthermore, as Misra et al scrutinize the safety and efficacy of chiropractic care for children, it should instead prioritize addressing its own challenges, particularly the widespread burden of preventable errors during birth.

These errors cause the very things that chiropractors end up triaging in their practices since the damage to the spine and nervous systems of these children are the result of medical errors caused by medical providers during pregnancy and birth.

A recent study published in the Journal of Pediatrics (Gupta R, Cabacungan ET. Neonatal birth trauma: Analysis of yearly trends, risk factors, and outcomes. J Pediatr. 2021;238:174–180.e3. doi:10.1016/j.jpeds.2021.06.080. Epub 2021 Jul 7) analyzed trends, risk factors, and outcomes associated with neonatal birth trauma using a weighted dataset of 982,033 records.

The results are absolutely shocking.

Over a nearly 10 year time span there was a 23% increase in the prevalence of neonatal birth trauma, rising from 25.3 to 31.1 per 1,000 hospital births. Scalp injuries accounted for 80% of all birth traumas, with their rate increasing annually from 19.87 to 26.46 per 1,000 hospital births. Major birth trauma, including clavicular fractures, brachial plexus injuries, and intracranial hemorrhage were 4.67 per 1,000 hospital births. Major birth trauma was linked to significantly higher odds of severe complications, such as hypoxic-ischemic encephalopathy, seizures, mechanical ventilation, meconium aspiration, and sepsis. Additionally, these cases were associated with a 56% longer hospital stay and nearly double the total medical charges compared to cases involving scalp injuries.

Whether or not Misra and his medical colleague were aware of this is one issue but certainly their token chiropractor Dr. Long who claims to specialize in maternal and pediatric chiropractic care should have known this.

Use of Weasel Words

The authors employ vague, loaded language (weasel words) to critique chiropractic care without providing concrete evidence. Examples include phrases such as "limited quality and low supporting evidence," "may risk harm," and "potential bias." These rhetorical devices imply doubt and criticism while avoiding direct claims or substantiation. Such language undermines the ability of parents and patients to make informed decisions, eroding their autonomy.

Violations of the Evidence-Informed Model

The authors’ approach contradicts the principles of Evidence-Informed Practice, which integrates all levels of research evidence, clinical expertise, and patient values. Misra et al. heavily prioritize randomized controlled trials (RCTs) while dismissing observational studies, case reports, and patient-reported outcomes. This selective adherence to evidence creates a false impression of inadequate support for chiropractic care.

Selective Citation: Misra et al. rely on systematic reviews highlighting limitations of chiropractic studies but fail to engage with research demonstrating its efficacy.
Dismissal of Observational Data: Parent-reported improvements in conditions like colic or headaches are disregarded as biased without contextualizing their relevance in pediatric care.
Overemphasis on Limitations: The authors disproportionately focus on methodological flaws in studies supporting chiropractic care while ignoring similar issues in critical studies.

Refuting the "Paucity of Evidence" Claim

Misra et al. assert a lack of best practices and evidence for pediatric chiropractic care, a claim that is demonstrably false. The Pediatric Best Practices document by Alcantara et al. (Alcantara J, Alcantara JD, Alcantara J, Kent C, McCoy M, Kwon C, et al. Pediatric best practices: guidelines for the chiropractic care of children. Ann Vertebral Subluxation Res. 2022;1–59) outlines comprehensive guidelines grounded in evidence-informed practices. These guidelines integrate diverse research levels and emphasize:

Evidence-Informed Practice: Incorporating observational research, case studies, RCT’s and clinical expertise.
Unique Biomechanical Considerations: Addressing pediatric spinal biomechanics to tailor chiropractic adjustments.
Patient-Centered Care: Prioritizing parental education and shared decision-making.

The dismissal of this robust framework exposes the contrived nature of Misra et al.'s "paucity of evidence" narrative.

Addressing the Vohra Study

Misra et al. cite the systematic review by Vohra et al. as evidence of adverse events associated with pediatric chiropractic care, ignoring Alcantara’s critical appraisal of the study (Alcantara J. A critical appraisal of the systematic review on adverse events associated with pediatric spinal manipulative therapy: A chiropractic perspective. J Pediatr Matern Fam Health Chiropr. 2010;1:22–29).

Key points from Alcantara include:

Inflated Risk Perception: Of the 14 cases cited over a 104-year span, most were minor, self-limiting events. Severe cases often involved pre-existing conditions or other confounding factors.
Selective Evidence: Vohra et al. disregarded 32 studies reporting no adverse events while including anecdotal and outdated references.
Misclassification of Adverse Events: Events categorized as moderate or severe were often routine or unrelated to chiropractic care.

By relying on a flawed study without addressing its critiques, Misra et al. perpetuate misinformation.

Broader Context of Pediatric Care

It is important to emphasize that chiropractic care is not intended to treat specific diseases such as those Misra et al. highlight in their critique. Instead, chiropractic care is fundamentally salutogenic in nature, focusing on promoting overall health and well-being by addressing the root causes of dysfunction rather than merely managing symptoms as Misra and their medical colleagues routinely do. Central to chiropractic philosophy is the understanding that the nervous system controls all functions of the body, and that removing obstructions to nervous system function—through techniques like spinal adjustments—can support the body’s innate ability to heal and maintain balance.

While critics like Misra et al. dismiss such approaches due to "insufficient evidence," they ignore the broader framework of evidence-informed care that integrates clinical expertise, observational data, and patient-reported outcomes alongside other studies.

Chiropractic care, by focusing on addressing biomechanical dysfunction and supporting the nervous system, avoids the inherent risks of iatrogenesis while promoting overall health—a stark contrast to the systemic issues pervasive in conventional medical treatment of pediatric patients.

Conclusion

Misra et al.’s critique of pediatric chiropractic care is undermined by biased rhetoric, selective evidence, and failure to adhere to evidence-informed principles. Their reliance on flawed studies like Vohra’s and omission of robust guidelines such as the Pediatric Best Practices document reveal an agenda aimed at discrediting chiropractic care rather than fostering informed, patient-centered healthcare. The safety, efficacy, and value of pediatric chiropractic care are supported by evidence that Misra et al. choose to ignore, rendering their conclusions both misleading and unscientific.