Statement on paediatric care

Codes and guidelines

29 November 2023

The Chiropractic Board of Australia

The role of the Chiropractic Board of Australia (the Board) is to protect the public in accordance with the Health Practitioner Regulation National Law (the National Law), as in force in each state and territory. The Board does this through its work in the National Registration and Accreditation Scheme (the National Scheme) in partnership with the Australian Health Practitioner Regulation Agency (Ahpra).

The core role of the Board and Ahpra is to protect the public. All chiropractors have a duty to make safe and effective patient care their primary concern.

The Board’s position on paediatric care

The intent of this position statement is to clarify the Board’s expectations regarding paediatric care by chiropractors.

Chiropractors receive extensive tertiary education and training to provide care across the lifespan.

In caring for children, chiropractors provide a range of treatment modalities that may include manual therapy such as mobilisation, soft tissue therapy, manipulation, and/or advice relating to exercise and other lifestyle factors relevant to the child’s age, condition and concern.

When chiropractors do not have the clinical skills and knowledge to appropriately assess or manage a paediatric patient, the Board expects them to refer the patient to another healthcare practitioner(s) who have the appropriate skills, or to co-manage the patient with the other healthcare practitioner(s).

What the Board expects

The Board’s standards, codes and guidelines set out its expectations of practitioners in delivering effective healthcare within an ethical framework.

These include the:

Code of conduct (2022) (the Code)
Guidelines for advertising a health service (2021) (the Advertising guidelines) and
Evidence-based practice fact sheet (2023).

While this Statement on paediatric care provides specific reference to relevant regulatory documents in the boxes below, the Board expects chiropractors to read and understand all registration standards, codes, guidelines, fact sheets and statements.

There are considerations, responsibilities and differences in the provision of care for children. The Board expects chiropractors to:

understand that children have significant anatomical, physiological, developmental and psychological differences and needs from adults and that their healthcare management
requires specific skills and expertise
modify all care and treatment (including technique and force) to suit the age, presentation and development of the patient
discuss their proposed management plan with the patient and their parent/guardian
inform the patient and their parent/guardian about the quality of the acceptable evidence and explain the basis for the proposed treatment
provide the patient and their parent/guardian with information about the risks and benefits of the proposed treatment and the risks of receiving no treatment
appropriately document consent, including considering the need for written consent for high-risk procedures
refer patients when they have conditions or symptoms outside a chiropractor’s area of competence, for example ‘red flags’ such as the presence of possible serious pathology that requires urgent medical referral to the care of other registered health practitioners
communicate effectively with other health practitioners involved with the care of the patient, such as the patient’s general practitioner or paediatrician.

Best practice and evidence-based care

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Best-practice approaches to providing chiropractic care to children are published in peer-reviewed literature. This evidence should be used to guide clinical practice and ensure chiropractors provide safe care. Current evidence indicates that the incidence of serious adverse events, either directly from manual therapy or indirectly by delayed referral or misdiagnosis, is very rare but can occur.

The Board expects chiropractors to make sure their clinical practice is consistent with current peer-reviewed evidence and/or best-practice approaches.

Where can you find more information in our regulatory documents?

Code of conduct

Principle 1 of the Board’s Code of conduct says that practitioners should practise safely, effectively and in partnership with patients and colleagues, using patient-centered approaches, and informed by the best available evidence to achieve the best possible patient outcomes. Principle 11 outlines that practitioners should recognise the vital role of ethical and evidence-based research to inform quality healthcare.

The Code outlines in section 4.3 the Board’s expectations on caring for children and young people, including that good chiropractic practice involves placing the interests and wellbeing of the child or young person first.

The Code also states in section 6.1 that good practice includes ensuring services provided are appropriate, necessary and likely to benefit the patient and requires practitioners in section 6.3 to understand and apply principles of public health and use the best available evidence in making practice decisions.

Guidelines for advertising a regulated health service

Section 4.1 of the Guidelines for advertising a regulated health service outlines how advertising may be false, misleading or deceptive including:

when it makes statements about effectiveness of treatment that are not supported by acceptable evidence
when it makes unqualified claims about the effectiveness of treatment by listing health conditions that a treatment or service can ‘assist with’ or treat.

Evidence-based practice fact sheet

The Board’s Evidence-based practice fact sheet advises that evidence-based practice involves a practitioner considering the available research and other sources of information in addition to their clinical experience and the patient’s values during their clinical decision-making process. Where there is evidence that a form of care is inappropriate or unsafe, a practitioners’ clinical experience should not be used to override the evidence.

Current best evidence is up to date information from relevant, valid research about the effects of different forms of healthcare. There is a wide range of evidence about chiropractic healthcare. The fact sheet provides further detail and a hierarchy of evidence scale.

Ensuring informed consent

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Informed consent is a patient’s voluntary decision about healthcare that is made with knowledge and understanding of the benefits and risks involved. This is important to ensure patients have relevant information before making a decision about care. For children this includes the consent of a parent, carer, guardian or other substitute decision maker (parent/guardian) as appropriate. Informed consent needs to be specific to the patient’s condition and the recommended treatment.

A chiropractor should consider the age, maturity and intellectual capacity of young people and other groups that may have additional needs and provide information in a way that they can understand. An older child with the ability to understand should be encouraged to participate in the discussion.

Where can you find more information in our regulatory documents?

Code of conduct

The Board’s Code of Conduct outlines at section 4.2 that good practice in relation to informed consent includes that you:

act according to the patient’s capacity for decision-making and consent, including when caring for children and young people, based on their maturity and capacity to understand, and the nature of the proposed care. Practitioners should consider the need for the consent of a parent, carer, guardian or other substitute decision maker.
get informed consent from the patient or where the patient does not have the capacity, from their parent, guardian or substitute decision-maker before carrying out any examination or investigation or providing treatment. When obtaining informed consent practitioners should include information on material risks and expected outcomes and take into account any advance care directive (or similar)
document consent appropriately, including considering the need for written consent for procedures which are of a higher risk or may result in serious injury or death.

Guidelines for advertising a regulated health service

Section 4.1 of the Guidelines for advertising a regulated health service outlines how advertising may be false, misleading or deceptive including:

when it minimises, underplays or under-represents the risk or potential risk associated with a treatment or procedure.

Evidence-based practice fact sheet

The Board’s Evidence-based practice fact sheet advises that in cases where there is only low-level evidence to support a particular treatment choice the practitioner should inform the patient of this fact. The patient can be informed that it is the practitioner’s clinical experience that the treatment may be effective for the presenting condition. Without this information the patient is unable to make an adequately informed decision about their healthcare.

A practitioner’s role is to be an advisor who empowers informed patient decisions.

Practicing within the chiropractor’s skills, competence and expertise

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The Council on Chiropractic Education Australasia’s Competency Standards for graduating chiropractors identify the measurable levels of knowledge, skills, attitudes, values and professional capabilities required to competently practise as a chiropractor in Australia. The competency standards describe the threshold level of competency expected for initial registration and continuing practice.

Continuing professional development (CPD) is an important way for practitioners to maintain and improve knowledge and skills and stay up to date in their area of practice. The National Law requires health practitioners complete CPD and the Board’s Registration standard Continuing professional development (2019) sets out the expectations.

Practitioners should routinely apply self-reflection, practice improvement and performance-appraisal processes to critically evaluate their strengths and weaknesses to maintain their professional expertise.

Where can you find more information in our regulatory documents?

Code of conduct

Principle 7 of the Board’s Code of conduct says that minimising risk to patients involves putting patients first by maintaining professional capability through ongoing professional development and self-reflection and understanding and applying the principles of clinical governance, risk minimisation and management in practice.

The Code outlines in section 7.3 the Board’s expectations including that good chiropractic practice requires practitioners to maintain and develop appropriate and current knowledge, skills and profession behaviours; and at section 7.4 to keep knowledge and skills up to date to ensure practitioners continue to work within their competence and scope of practice.

Guidelines for advertising a regulated health service

Section 4.1 of the Guidelines for advertising a regulated health service outlines how advertising may be false, misleading or deceptive including:

when it compares health outcomes, regulated health professions or practitioners or prices without complete information.
when it makes claims about providing a superior regulated health service

Evidence-based practice fact sheet

The Board’s Evidence-based practice fact sheet advises that a practitioner’s clinical experience ranks as a very low level of evidence because of the small sample size and the lack of control for factors including placebo effect. As a result, practitioners should recognise that their clinical experience cannot be used to justify treatment when there is good evidence for the efficacy of other treatment modalities that is contradictory.

Advertising practices in accordance with regulatory expectations

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Advertising is an important way that chiropractors can promote their services to the public. As advertising can influence a patient’s decision-making about their health care needs it is important for patients to have access to information that is accurate, supported by acceptable evidence and not misleading. Advertising should not encourage a patient to seek chiropractic care in the absence of a link to a specific condition or symptom and any claims need to be supported by acceptable evidence.

The National Law establishes the requirements for advertising a regulated health service. These requirements are important for public protection and help to ensure the public receives accurate and honest information about healthcare services.

There is an important difference between acceptable evidence for claims made in advertising and the evidence used for clinical decisions about patient care. When treating patients, chiropractors must obtain informed consent for the care provided and are expected to discuss the evidence for different treatment options. In advertising, the claims are generic, and practitioners are not available to clarify whether a treatment is appropriate for an individual patient.

The Check your advertising: Chiropractic examples explain that there is insufficient acceptable evidence to support claims in advertising that there is a relationship between manual therapy (e.g. spinal adjustments and/or manipulation) for spinal problems and achieving general wellness or treating various organic diseases and infections; or that spinal problems may have a direct role in the genesis of various organic diseases and infections.

Where can you find more information in our regulatory documents?

Code of conduct

The Code of conduct in section 8.5 states that good practice involves complying with the advertising requirements of the National Law, which are explained in the Guidelines for advertising a regulated health service.

Guidelines for advertising a regulated health service

These guidelines were developed to help advertisers understand their obligations when they are advertising a regulated health service. The guidelines, together with the resources published on Ahpra and National Board websites, support compliance with the National Law’s advertising requirements.

Check your advertising: Chiropractic examples

Provides information and examples of advertising claims that don’t meet the legal requirements.