Milne et al. BMC Pediatrics (2022) 22:721 https://doi.org/10.1186/s12887-022-03781-6 RESEARCH © The Author(s) 2022. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http:// creat iveco mmons. org/ licen ses/ by/4. 0/. The Creative Commons Public Domain Dedication waiver (http:// creat iveco mmons. org/ publi cdoma in/ zero/1. 0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Open Access Spinal manipulation and mobilisation in the treatment of infants, children, and adolescents: a systematic scoping review Nikki Milne1,2*, Lauren Longeri1, Anokhi Patel1, Jan Pool3, Kenneth Olson4, Annalie Basson5 and Anita R. Gross6 Abstract Purpose: To i) identify and map the available evidence regarding effectiveness and harms of spinal manipulation and mobilisation for infants, children and adolescents with a broad range of conditions; ii) identify and synthesise policies, regulations, position statements and practice guidelines informing their clinical use. Design: Systematic scoping review, utilising four electronic databases (PubMed, Embase, CINHAL and Cochrane) and grey literature from root to 4th February 2021. Participants: Infants, children and adolescents (birth to < 18 years) with any childhood disorder/condition. Intervention: Spinal manipulation and mobilisation Outcome measures: Outcomes relating to common childhood conditions were explored. Method: Two reviewers (A.P., L.L.) independently screened and selected studies, extracted key findings and assessed methodological quality of included papers using Joanna Briggs Institute Checklist for Systematic Reviews and Research Synthesis, Joanna Briggs Institute Critical Appraisal Checklist for Text and Opinion Papers, Mixed Methods Appraisal Tool and International Centre for Allied Health Evidence Guideline Quality Checklist. A descriptive synthesis of reported findings was undertaken using a levels of evidence approach. Results: Eighty-seven articles were included. Methodological quality of articles varied. Spinal manipulation and mobi- lisation are being utilised clinically by a variety of health professionals to manage paediatric populations with adoles- cent idiopathic scoliosis (AIS), asthma, attention deficit hyperactivity disorder (ADHD), autism spectrum disorder (ASD), back/neck pain, breastfeeding difficulties, cerebral palsy (CP), dysfunctional voiding, excessive crying, headaches, infantile colic, kinetic imbalances due to suboccipital strain (KISS), nocturnal enuresis, otitis media, torticollis and pla- giocephaly. The descriptive synthesis revealed: no evidence to explicitly support the effectiveness of spinal manipula- tion or mobilisation for any condition in paediatric populations. Mild transient symptoms were commonly described in randomised controlled trials and on occasion, moderate-to-severe adverse events were reported in systematic reviews of randomised controlled trials and other lower quality studies. There was strong to very strong evidence for ‘no significant effect’ of spinal manipulation for managing asthma (pulmonary function), headache and nocturnal enu- resis, and inconclusive or insufficient evidence for all other conditions explored. There is insufficient evidence to draw conclusions regarding spinal mobilisation to treat paediatric populations with any condition. *Correspondence: nmilne@bond.edu.au 1 Department of Physiotherapy, Faculty of Health Sciences and Medicine, Bond University, Queensland, Australia Full list of author information is available at the end of the article http://creativecommons.org/licenses/by/4.0/ http://creativecommons.org/publicdomain/zero/1.0/ http://creativecommons.org/publicdomain/zero/1.0/ http://crossmark.crossref.org/dialog/?doi=10.1186/s12887-022-03781-6&domain=pdf Page 2 of 24Milne et al. BMC Pediatrics (2022) 22:721 Conclusion: Whilst some individual high-quality studies demonstrate positive results for some conditions, our descriptive synthesis of the collective findings does not provide support for spinal manipulation or mobilisation in paediatric populations for any condition. Increased reporting of adverse events is required to determine true risks. Randomised controlled trials examining effectiveness of spinal manipulation and mobilisation in paediatric popula- tions are warranted. Keywords: Spine, Manipulation, Mobilisation, Infant, Child, Adolescent Background Various healthcare professionals utilise manual ther- apy including spinal manipulation and or mobilisation as a treatment modality for musculoskeletal and non- musculoskeletal conditions. These treatment modalities are being  utilised  to treat paediatric clients, including infants, young children and adolescents with a variety of acute and chronic conditions [1, 2]. Manual therapy is an umbrella term that encompasses any hand move- ment that produces a physiological or mechanical change in soft tissue and joints [3]. Spinal mobilisation is one form of manual therapy which may be used after a thorough and extensive clinical reasoning process. It comprises a continuum of skilled passive movements applied  to the spine  at varying speeds and amplitudes, impacting  joints, muscles or nerves with the intent to restore optimal motion and function, and to reduce pain [3]. Spinal manipulation is another form of manual therapy and is defined in Australian Health Practitioner Regulation National Law as “any technique delivered by any health  professional that involves a high velocity, low amplitude (HVLA) thrust beyond the usual physi- ological range of motion, impacting the spine, within the limits of anatomical integrity” [4]. The International Chiropractic Association (ICA) utilises two terms that fit within this definition; i) ‘Spinal Adjustment’—a specific directional thrust that is believed to set the vertebra into motion with the intent to improve or correct vertebral subluxation or malposition, reducing or correcting neu- roforaminal / neural canal encroachment and; ii) ‘Spi- nal Manipulation’ – a specific thrust to a spinal joint to mobilise the joint or put it through its range of motion [5]. Whereas, the International Federation of Orthopae- dic Manipulative Physical Therapists (IFOMPT), refer to spinal manipulation as a passive, HVLA thrust applied to a spinal joint complex within its anatomical limit, with the intent to restore optimal motion, function, and/or to reduce pain [6]. According to the World Health Organisation (WHO), regulations guiding the utilisation of spinal manual therapy and manipulation are consistent between coun- tries [7]. For example, in Australia, under the Health Practitioner Regulation Law  (ACT)  Sect.  123, a per- son must not perform spinal manipulation unless they are registered  practitioners  in  one of the following health professions: Chiropractic, Osteopathy, Medical or Physiotherapy [4]. This is consistent across several other countries including but not limited to the United States of America [8] and Canada [9]. Whilst not common in the physiotherapy profession [10] or used by some evidence- based chiropractors or osteopaths [11–13], the treatment of non-musculoskeletal conditions with spinal manipula- tive therapy is a long-standing tradition in chiropractic and osteopathic professions [14, 15] and this is based on the underpinning theory that spinal dysfunction, or sub- luxations can negatively impact the autonomic nervous system and the bodies self-healing ability [16–18], and spinal manipulation can remedy this by impacting the autonomic nervous system and improving physiological functions [19, 20]. There  is great  controversy  regarding  the safety and efficacy of spinal manipulation in paediatric populations [2].  An independent expert review was commissioned by Safer Care Victoria in October 2019 and aimed to identify evidence to support position statements for both  safety and efficacy  of spinal manipulation in children  under  12  years of age and resulted in recommendations to the Council of Australian Governments  [2, 21]. An announcement by health ministers  in Australia  regarding spinal manipulation ensued and prompted the Chiropractic Board of Australia to enforce an interim policy  prohibiting  the use of chiropractic spinal manipulation in children under the age of  two  years [22]. When exploring the appropriateness of utilising clinical interventions, it is important to explore both effectiveness and adverse events. An adverse event is any unfavourable sign, symptom or disease associated with treatment, despite whether it was caused by the treatment [23]. Patient harm creates both a burden to patients and their families, and strains health system finances significantly. This leads to increased levels of care and resource utilisation [24]. Whilst several reviews of varying methodological qual- ity have explored the effects and adverse events from spi- nal manipulation in paediatric populations [1, 21, 25–27], there have been conflicting findings published addressing a broad spectrum of conditions and there has been little exploration of the policies, guidelines, regulations or laws, Page 3 of 24Milne et al. BMC Pediatrics (2022) 22:721 supporting or prohibiting the use of spinal manipula- tion or mobilisation in the management of infants, chil- dren and adolescents. Some reviews on this topic have limited their inclusions to explore the effects or harms in infants, and there has been less exploration of the effects or harms of spinal manipulation and mobilisation of chil- dren aged 12 years or older. The conflicting information in published reviews conducted to date,  appears to be due, at least partially, to the inclusion of low-quality research or lack of critical appraisal for included studies [28–30]. There has been limited publication of policies, guide- lines and position statements regarding the use of spinal manipulation and mobilisation of paediatric clients, with only one review exploring this in paediatric populations from birth – 12  years [21]. Both the inconsistency of empirical research findings and the apparent lack of guid- ance documents to support or restrain practice in this clinical area, leaves both healthcare professionals and pae- diatric clients vulnerable to inappropriate, ineffective, or potentially harmful interventions and a broader synthesis of the collective literature to guide clinicians in this clini- cal area is warranted. The purpose of this systematic scoping review was to identify and map the available evidence related to the use of spinal manipulation and mobilisation techniques in the treatment of infants, children and adolescents with a variety of common paediatric conditions. This systematic scoping review was planned as a joint investigation by the International Federation of Orthopaedic Manipulative Physical Therapists [IFOMPT] and International Organi- sation of Physical Therapists in Paediatrics [IOPTP] to inform future position statements on this clinical practice topic and guide more focused research investigations if warranted. In this systematic scoping review, we identi- fied and mapped the results of empirical research, reviews of empirical research, published guidelines for practice, policies and position statements. In relation to infants, children and adolescents, we addressed the following questions: 1. What conditions are being managed with spinal manipulation and mobilisation? 2. Is spinal manipulation and mobilisation effective? 3. Is spinal manipulation and mobilisation harmful? 4. Are there policies, regulations, position statements and practice guidelines informing the clinical use of spinal manipulation and mobilisation? Methods The PRISMA statement extension for scoping reviews (PRISMA-ScR) was used to guide the reporting of this systematic scoping review [31]. The review protocol was registered with Open Science Framework on June 14, 2020 (Retrieved from https:// osf. io/ zm8e6) prior to conducting the search. Identification and selection of studies After consulting with the Health Sciences and Medicine Faculty librarian at the host university, the appropriate Medical Subject Headings (MeSH terms) and Boolean operations were incorporated before the empirical  lit- erature  was  systematically searched, combining  syno- nyms for “infant”, “child” and “adolescent”, and key words related to “spinal manipulation” and “spinal mobilisa- tion”, followed by outcomes associated with  common childhood  conditions. The following databases were searched: PubMed, Embase, CINAHL and Cochrane. Grey literature was searched using Google utilising key terms including “paediatric” (and associated synonyms) AND “spinal manipulation” OR “spinal mobilisation” (and associated synonyms) AND “policies” OR “guide- lines” OR “statements”, hand-searching reference lists from all included research articles and reviewing arti- cles via expert referral of relevant literature. The search strategy was wide in scope to support the nature of the review and details on the search strategy are presented in Supplementary File 1. The four databases were searched from root up to 18 June 2020 with an updated search up to 4th Febru- ary 2021. To identify relevant grey literature, a  google search for files ending with [file: PDF] and [file: doc] was conducted. The initial and follow-up search was per- formed  independently  by  two authors  (A.P. and L.L.). Studies were gathered, and duplicates were removed using EndNote (Endnote Version X9.1.1, Clarivate Ana- lytics; 2019). Once duplicate articles were removed, two authors (A.P. and L.L.) independently conducted title and abstract screening to identify potentially relevant articles for full-text review. After undertaking an initial process of consensus, outstanding disagreements between two authors (A.P. and L.L.) were resolved by a third author (N.M.). Studies that appeared to meet the inclusion cri- teria at title and abstract screening stage were retrieved in full text. Eligibility criteria were applied. Table 1 pro- vides a comprehensive  list of the inclusion criteria for both research articles and grey literature.  Studies were excluded if individuals were aged over 18 years, if man- ual therapy techniques were applied to areas of the body other than the spine, if paediatric data was unable to be extracted from mixed populations or if it was an ani- mal study. Grey literature was searched to gain a deeper understanding of current professional services regard- ing the use of spinal manipulation and or mobilisation. We excluded documents that did not have an attributed author or publisher and protocols with no full published https://osf.io/zm8e6 Page 4 of 24Milne et al. BMC Pediatrics (2022) 22:721 study were excluded. To achieve a final consensus on included full text articles, all discrepancies were resolved by a third reviewer (N.M.). Reference  lists of included articles were  hand-searched  for other  possible  arti- cles that may have been missed during the initial search. The results of the search are presented in flowchart for- mat according to the PRISMA extension for scoping reviews (PRISMA-ScR) [31]. Assessment of characteristics of reviews and studies Quality appraisal The quality assessment process was independently conducted by two authors (A.P. and L.L.) (see Supplementary File 2) and a summary of the critical appraisal scores has been summarised. Cohen’s kappa statistic was applied to determine the level of agreement in scoring between the two reviewers and disagreements were settled by a third  reviewer (N.M.).  The following critical appraisal tools were used to assess quality due to diversity of  included study designs, while grey literature which did not fulfil the critical appraisal tools below were not critically appraised. 1. The Joanna Briggs Institute (JBI) Checklist for  Sys- tematic Reviews and Research Synthesis was used to assess  quality of  included  Systematic Reviews [32] (Supplementary File 2). This tool includes 11 domains and criteria were assessed using the following scoring: ‘yes’ scoring ‘1’ and ‘no’ or ‘unclear’ scoring ‘0’. 2. The Mixed Methods Appraisal Tool (MMAT) was used to assess the quality of the  quantitative  and qualitative studies [33] (Supplementary File 2). MMAT appraises quality of five categories including qualitative research, randomised control trials (RCT), non-randomised studies, quantitative descriptive studies and mixed methods studies. Criteria were assessed by scoring ‘yes’ as ‘1’ and ‘no’ or ‘can’t tell’ as ‘0’. 3. The International Centre for Allied Health Evi- dence  Guideline  Quality Checklist (ICAHE) was used to  assess  the quality of guidelines included in grey literature [34] (Supplementary File 2). This tool includes six domains: availability, dates, underlying evidence, guideline developers, guideline purpose and users, and ease of use. Criteria were assessed by scoring ‘yes’ as ‘1’ and ‘no’ as ‘0’. 4. The Joanna Briggs Institute (JBI) Critical Appraisal Checklist for Text and Opinion Papers was used to assess quality of  the text and opinion papers [35] (Supplementary File 2). This tool includes six domains:  source, expertise, relevant population, logic, reference to the literature and incongruence with the literature. Criteria were assessed by scoring ‘yes’ as ‘1’ and ‘no’ or ‘unclear’ as ‘0’. Data extraction and analysis Data was extracted independently by two authors (A.P. and L.L.) using a standardised  pre-piloted  data extrac- tion form (see Supplementary File 3) to collect rel- evant information including study design, participant characteristics, intervention and outcome measures. A third author (N.M.) ensured accuracy and validity of extracted data. Information relating to adverse events and harms were extracted from systematic reviews and individual studies when reported.  Adverse events were then classified using a modified version of the common Table 1 Inclusion Criteria Design • Full-text articles published in English language only • Research articles: systematic reviews, randomised controlled trials (RCTs), intervention studies, observational studies, cross sectional studies • Grey literature: policies, procedures, guidelines, recommendations, position statements or perspectives (including commentaries, opinions and editorials) Participants • Study participants must be male or female infants (0 to < 2), children (2 to 12) or adolescents (13 to < 18) (WHO, 2006) Intervention • Study participants must have had spinal manipulation and/or spinal mobilisation carried out by health professionals with an international body guiding their practice Outcome • Patient/caregiver reported outcome (PRO), observation-based outcomes, other structure impairment, reports, policy statement or recommendation statement related to body function or structure impairment, activity limitation or participation restriction • Adverse events and harms Comparison (for intervention studies) • Any comparison group in a randomised or non-randomised study: placebo, waitlist, no treatment, adjunct treatment, or comparison intervention Page 5 of 24Milne et al. BMC Pediatrics (2022) 22:721 terminology criteria for adverse events (CTCAE) pub- lished in the Adverse Event Reporting Requirements by the National Cancer Institute [36] and were considered ‘mild’ – if individuals were experiencing mild symp- toms requiring self-care only; ‘moderate’—if symptoms were limiting age-appropriate activities of daily living or requiring care from a physician and; ‘severe’ – if expe- riencing medically significant symptoms leading to a life-threatening outcome resulting in urgent interven- tion, hospitalisation or death [36]. Authors of papers were contacted to request missing or additional data if required. All included articles were reviewed to identify the pre- senting paediatric conditions being treated with spinal manipulation and/or mobilisation. The form of interven- tion used in the studies was identified and classified as “spinal manipulation”, “spinal mobilisation” or a combina- tion of both alongside other treatment  modalities  (e.g., “soft tissue massage” or “exercise”). For transparency of overlap between studies and reviews, a matrix (Supple- mentary File 4) was developed to identify the percentage of overlap for included studies which were already repre- sented in the included review articles. Only studies that achieved 5/7 or more on critical appraisal (i.e., higher quality studies), would also be included in the descrip- tive synthesis using a levels of evidence approach. Infor- mation from each systematic review was extracted and represented according to the focus of the paediatric con- ditions and impairments. After data extraction, a descriptive synthesis was com- pleted to explore the effectiveness of spinal manipula- tion and mobilisation with paediatric populations. The descriptive synthesis involved two stages. Initially, the results from investigations (reviews and studies) were coded based on whether the effect was significantly posi- tive (i.e., favourable) ( +), negative (i.e., unfavourable) ( −), had no significant effect (0) or was inconclusive (Inc – for reviews only). For individual studies with control groups when there was no difference in effect between control (standard care) and intervention groups (standard care, plus spinal manipulation or mobilisation), a code of zero (0) was applied, or a statistically significant difference (p < 0.05) favouring the intervention group or control group was coded (+ or -) respectively [37]. Results from systematic reviews were only included in the descriptive synthesis when more than one study was synthesised in the review and was relevant to the outcome explored in that review. If only one study was included in a review, that study was identified in the individual studies, inclu- sion and exclusion criteria were applied, as were critical appraisal methods. To be included in the descriptive syn- thesis, studies had to be of good methodological qual- ity scoring at least five out of seven on the MMAT tool. Reviews that did not synthesise data were excluded from the descriptive synthesis stage of analysis. Finally, to ensure that findings reported were from the highest available level of evidence, a levels of evi- dence approach adapted from previously published lit- erature [37–40] was utilised to assess both the quality and quantity of evidence (reviews and studies) relating to the outcomes for defined impairments for each con- dition (Fig. 1). After following the decision tree in Fig. 1 which is based on the quality of evidence and quantity of such evidence, the levels of evidence statements avail- able for each outcome were: Very strong, strong, moder- ate or limited evidence for a positive (favourable) effect, negative (unfavourable) effect or no significant effect. Consistent positive results (≥ 66.6% of relevant investi- gations at the identified level reporting significant posi- tive results) or consistent negative (66.6% of relevant investigations at the identified level reporting significant negative results) were needed to achieve very strong, strong, moderate or limited levels of evidence state- ments. Consistently no significant effect (≥ 66.6% of rel- evant investigations at the identified level reporting no significant effect) was required to determine that the intervention has ‘no significant effect’ on the condition/ outcome. If the above percentages were not reached and the results of the decision tree were mixed, the evidence for that intervention was deemed to be ‘inconclusive’ and if there were insufficient studies / reviews exploring the intervention for the identified condition / outcome, then ‘insufficient’ evidence was documented for the lev- els of evidence statement. If evidence from the system- atic reviews resulted in statements of ‘insufficient’ or ‘inconclusive’, collective results from individual studies (if available) were utilised for the final level of evidence statement. All levels of evidence are based on previ- ously published National Health and Medical Research Council (NHMRC) levels of evidence hierarchy for stud- ies [40] and JBI levels of evidence for systematic reviews [39]. The level of evidence utilised are summarised in Table 2 below. Results Flow of studies through the scoping review The initial literature search yielded 3866 papers (Fig.  2) with 95 additional studies included from scanning refer- ence lists or other sources, and after applying the inclu- sion and exclusion criteria in the screening process, 348 full text articles were assessed for eligibility and 87 arti- cles met the eligibility criteria (Table 1). Of the 87 included articles, 35 were systematic reviews with seven being level 1a reviews according to the JBI Levels of Evidence for Systematic Reviews [1, 41–46], 16 RCT’s, 11 other studies (n = 2 surveys, n = 1 naturalistic Page 6 of 24Milne et al. BMC Pediatrics (2022) 22:721 study, n = 5 cohort studies, n = 1 prospective outcome study, n = 1 retrospective study, n = 1 feasibility study), two guidelines, 14 text and opinion papers and nine pol- icy and policy developments (Fig. 2). The matrix presented in Supplementary File 4 revealed that only 1 systematic review [21] captured a large proportion of the studies from the present scop- ing review. The descriptive synthesis in the present Fig. 1 Flow chart of decision-making process for levels of evidence approach, based on study design, quality and quantity Page 7 of 24Milne et al. BMC Pediatrics (2022) 22:721 scoping review was undertaken for reviews, and studies (scoring ≥ 5/7 on the MMAT) independently and any differences are discussed below. Characteristics of the included studies Quality A summary of critical appraisal consensus scores for all studies and grey literature is reported in Table  3 with a detailed breakdown of individual critical appraisal scores in Supplementary File 2. There was moderate inter-rater agreement on the critical appraisal score between the two independent reviewers (κ = 0.61, p = < 0.001). After a process of consensus, 100% agreement was achieved for all papers during the consensus process. Critical appraisal revealed that review articles generally scored poorly in questions regarding methods to minimise errors in data extraction, and in their assessment of the likelihood of publication bias. Regarding grey literature (see Supplementary File 2), one guideline lacked underlying quality of evidence [47]. Critical appraisal revealed the methodological quality of text and opinion papers was mostly reduced due to poor reporting of the source of opinion, not using an analytical process to form an opinion, or logically defending incongruences in the literature (see Supplementary File 2). Participants Participants represented in both the systematic reviews and studies ranged from birth to ≤ 18  years (Supplementary File 3). The included articles assessed the effects of spinal manipulation or mobilisation to manage a variety of impairments related to many dif- ferent conditions, including: adolescent idiopathic sco- liosis (AIS), asthma and breathing difficulties, autism spectrum disorder (ASD), attention deficit-hyperac- tivity disorder (ADHD), back/neck pain, breastfeeding difficulties, cerebral palsy (CP), dysfunctional voiding, headache, infantile colic (excessive crying and sleep disturbances), kinetic imbalance due to suboccipital strain (KISS) disorder, nocturnal enuresis, otitis media, torticollis and plagiocephaly. Supplementary File 3 presents a detailed description of all included articles with relevant data extracted. Table 4 outlines the num- ber of included articles exploring spinal manipulation and mobilisation according to study design and age groups explored. Intervention Interventions explored in the present systematic scoping review included spinal manipulation and mobilisation. These interventions were conducted by health profes- sionals with guiding international professional bod- ies [65, 111–113] including chiropractors (18 reviews, Table 2 Levels of Evidence Definitions used for Descriptive Synthesis RCT Randomised Controlled Trials, NHMRC National Health and Medical Research Council, JBI Johanna Briggs Institute Source: [39, 40] Level of Evidence Study Types Reviews (JBI, 2013) Level 1 Level 1.a – Systematic review of Randomised Controlled Trials (RCTs) Level 1.b – Systematic review of RCTs and other study designs Level 2 Level 2.a – Systematic review of quasi-experimental studies Level 2.b – Systematic review of quasi-experimental and other lower study designs Level 3 Level 3.a – Systematic review of comparable cohort studies Level 3.b – Systematic review of comparable cohort and other lower study designs Level 4 Level 4.a – Systematic review of descriptive studies Studies (NHMRC, 2009) II A randomised controlled trial III-1 A pseudorandomised controlled trial (i.e., alternate allocation or some other method) III-2 A comparative study with concurrent controls: ▪ Non-randomised, experimental trial ▪ Cohort study ▪ Case–control study ▪ Interrupted time series with a control group III-3 A comparative study without concurrent controls: ▪ Historical control study ▪ Two or more single arm study ▪ Interrupted time series without a parallel control group IV Case series with either post-test or pre-test/post-test outcomes Page 8 of 24Milne et al. BMC Pediatrics (2022) 22:721 8 RCTs, 10 other studies), physiotherapists (4 RCTs) a combination of chiropractors, osteopaths, physiothera- pists and/or manual therapists (17 reviews and 2 RCTs), medical doctors specialising in manual therapy (2 RCTs) and a manual therapist (not otherwise defined) (1 RCT and 1 other study). Below is a summary of findings from the included reviews and studies, including the results from the descriptive synthesis in Supplementary File 5 regarding the effectiveness of spinal manipulation and mobilisation. The effects of spinal manipulation and mobilisation have been reported separately according to the conditions being managed in paediatric populations (see Supplementary File 5). Effects of spinal manipulation in infants, children and adolescents Of the 35 included reviews, 24 investigated the effective- ness of spinal manipulation in paediatric clients and pro- duced quantifiable results which could be utilised in the descriptive synthesis (Supplementary File 5). Three were focused on treatment for AIS [104, 106, 107], seven on asthma [1, 21, 45, 91, 96, 98, 104], two for ASD [51, 102], two on spinal pain [104, 109], four on breastfeeding dif- ficulties for infants [28, 30, 99, 104], two on CP [25, 104], 15 on infantile colic—excessive crying / behaviours [1, 21, 25, 26, 42, 43, 66, 91, 96, 98, 103, 104], four on infan- tile colic – sleep issues [42, 66, 91, 104], five on noctur- nal enuresis [26, 44, 46, 96, 98], three on otitis media [98, 104, 105] and one on torticollis [62] (see Supplementary File 5). Additionally, there were four systematic reviews on adverse events from spinal manipulation [73, 100, 108, 110] and nine reported on multiple conditions including those mentioned above as well as neck and back pain, and upper cervical dysfunction [1, 21, 25, 26, 91, 96, 98, 104, 109]. From the 18 studies included in the descriptive synthe- sis that explored the effectiveness of spinal manipulation in paediatric populations, one was focused on AIS [59], two on asthma [49, 56], four on back/neck pain [57, 63, Fig. 2 PRISMA flow diagram [31] Page 9 of 24Milne et al. BMC Pediatrics (2022) 22:721 Table 3 Summary of Critical Appraisal Scores (CAS) JBI for Systematic Reviews MMAT- RCT’s MMAT- Other studies Grey Literature Author (Year) CAS Author (Year) CAS Author (Year) CAS Author (Year) CAS Alcantara, et al. (2011a) [48] 3/11 Balon (1998) [49] 7/7 Alcantara, et al. (2009) [50] 6/7 iCAHE – Clinical Guidelines Alcantara, et al. (2011b) [51] 8/11 Borusiak (2009) [52] 5/7 Davies & Jamison (2007) [53] 6/7 Council of Chiropractic Prac- tice (2008) [54] 13/14 Alcantara, et al. (2015) [55] 4/11 Bronfort et al. (2001) [56] 5/7 Hayden, et al. (2003) [57] 6/7 NSW Government (2016) [47] 9/14 Brand, et al. (2005) [41] 7/11 Browning and Miller (2008) [58] 7/7 Lantz and Chen (2001) [59] 5/7 Bronfort, et al. (2010) [1] 7/11 Cabrera-Martos, et al. (2016) [60] 7/7 Lebouef (1991) [61] 3/7 JBI for Text and Opinion Papers Brurberg, et al. (2019) [62] 6/11 Dissing, et al. (2018) [63] 6/7 Miller and Benfield (2008) [64] 7/7 World Federation of Chiroprac- tic (WFC) (2019) [65] 2/6 Carnes, et al. (2018) [66] 11/11 Evans, et al. (2018) [67] 6/7 Miller and Phillips (2009) [68] 5/7 Chiropractic Board of Australia (CBA) (2017) [69] 4/6 Clar, et al. (2014) [25] 10/11 Haugen, et al. (2011) [70] 5/7 Miller and Newell (2012) [71] 5/7 Chiropractors’ Association of Australia (CAA) (2016) [72] 4/6 Corso, et al. (2020) [73] 11/11 Kachmar, et al. (2018) [74] 7/7 Saedt, et al. (2018) [75] 5/7 International Chiropractic Association (ICA) (2019) [76] 6/6 Dobson, et al. (2012) [42] 10/11 Lynge, et al. (2021) [77] 6/7 Sawyer, et al. (1999) [78] 6/7 Barham-Floreani (2014) [79] 4/6 Driehuis, et al. (2019) [26] 10/11 Miller, Newell & Bolton. (2012) [80] 5/7 Zhang and Snyder (2004) [81] 5/7 Marron (2011) [82] 6/6 Edwards and Miller (2019) [28] 8/11 Nemett (2008) [83] 4/7 Chevrier (2016) [84] 6/6 Ellwood, et al. (2020) [27] 10/11 Olafsdottir, et al. (2001) [85] 7/7 Kirkey (May 2019) In College of Chiropractors of Ontario (2019) [86] 3/6 Ernst (2009) [43] 6/11 Reed (1994) [87] 2/7 Kirkey (July 2019) In College of Chiropractors of Ontario (2019) [88] 2/6 Fairest, et al. (2019) [29] 3/11 Selhorst and Selhorst (2015) [89] 7/7 Collie (2019) In College of Chiropractors of Ontario (2019) [90] 2/6 Ferrance and Miller (2010) [91] 3/11 Wiberg, et al. (1999) [92] 5/7 Lindsay (2019) In College of Chiropractors of Ontario (2019) [93] 3/6 Fry (2014) [30] 5/11 Rosner (2003) [94] 5/6 Glazener, et al. (2005) [44] 10/11 Australian Chiropractic Asso- ciation (ACA) (2019) [95] 4/6 Gleberzon, et al. (2012) [96] 10/11 Sellhorst (2015) [97] 5/6 Green, et al. (2019) [21] 10/11 Hawk, et al. (2007) [98] 8/11 Hawk, et al. (2019) [99] 11/11 Hondras, et al. (2005) [45] 10/11 Huang, et al. (2011) [46] 7/11 Humphreys (2010) [100] 5/11 Karpouzis, et al. (2010) [101] 7/11 Kronau, et al. (2016) [102] 11/11 Lucassen (2010) [103] 7/11 Parnell, et al. (2019) [104] 11/11 Pohlman & Holton-Brown (2012) [105] 8/11 Romano & Negrini (2008) [106] 6/11 Theroux, et al. (2017) [107] 10/11 Todd, et al. (2015) [108] 7/11 Vaughn, et al. (2012) [109] 11/11 Vohra et al. (2007) [110] 7/11 Key: JBI Joanna Briggs Institute for Systematic Reviews (0 to 11), MMAT Mixed Methods Appraisal Tool (0 to 7), iCAHE International Centre for Allied Health Evidence Guideline Quality Checklist (0–14), JBI Joanna Briggs Institute for Text and Opinion Papers (0–6), CAS Critical Appraisal Scores Page 10 of 24Milne et al. BMC Pediatrics (2022) 22:721 67, 89], one on CP [74], two on headache [52, 77], six on infantile colic – excessive crying / behaviours [53, 58, 68, 71, 85, 92], one on infantile colic – sleeping disturbances [58] and one on torticollis [70]. Only 14 of the 62 included research articles provided supporting evidence (e.g., references to other papers) of psychometric properties for the outcome measures being utilised in the research evaluations and none of the arti- cles provided actual psychometric values for reliability, validity and responsiveness, to suggest the selected out- come measure was a suitable tool to measure effective- ness of treatment. The findings from the descriptive synthesis using the levels of evidence approach are pro- vided below for each condition which met our methodo- logical thresholds for undertaking a descriptive synthesis. Adolescent idiopathic scoliosis (AIS) From three reviews [104, 106, 107] and one observational study [59] explor- ing spinal manipulative therapy for treating scoliosis, our descriptive synthesis revealed ‘inconclusive’ results for using spinal manipulation to manage impairments and symptoms of AIS (Table 5). Asthma From seven reviews [1, 21, 45, 91, 96, 98, 104] and two RCTs [49, 56], our >descriptive synthe- sis  revealed very strong evidence that spinal manipula- tion on paediatric populations had ‘no significant effect’ on pulmonary function and findings were inconclusive for peak expiratory flow, general asthma symptoms, severity levels and quality of life (Table 5). Autism spectrum disorder (ASD) Of the two reviews [102, 104], one concluded that there was a reduction in Autism related symptoms after spinal manipulation [102], however, results from this review must be inter- preted with caution as many included studies were case reports. There were no individual studies of good meth- odological quality exploring this topic included in the present scoping review. Our descriptive synthesis revealed ‘inconclusive’ findings for spinal manipulation to treat autism related impairments in children (Table 5). Attention deficit hyperactivity disorder (ADHD) Whilst our scoping review captured two systematic reviews that explored the effectiveness of spinal manipulation in pae- diatric populations with ADHD [21, 104], both reviews included the same single study on the topic, which was screened for inclusion in our review but excluded due to not meeting our definition for spinal manipulation. No additional studies were identified on this topic and sub- sequently there was not sufficient evidence to complete a descriptive synthesis on the effects of spinal manipulation for children with ADHD (Table 5). Spinal (Back / Neck) Pain (mixed acute and chronic pres- entations) Two reviews [104, 109] explored the effec- tiveness of spinal manipulation for managing low back pain severity, with one review [104] (n = 1 RCT and 1 observational study exploring 239 participants) conclud- ing favourable outcomes for reducing a mixture of acute and chronic back pain severity in children and adoles- cents, with the second review [109] finding inconclusive results regarding the effectiveness of spinal manipula- tion for managing a mixture of acute and chronic spinal pain. Additionally, four studies [57, 63, 67, 89] explored the effects of back and neck pain (with mixed acute and chronic presentations) in children and adolescents. One well powered RCT [67] showed spinal manipulation (added to exercise) had significant favourable effects on reducing chronic low back pain severity and one lower quality study [57] showed spinal manipulation resulted in significantly favourable reductions in severity of acute back pain. However, two additional RCTs [63, 89] and one other study [57] provided strong evidence that spi- nal manipulation had ‘no significant effect’ on spinal pain (mixed acute and chronic) severity in children and adolescents despite strong evidence of improvements in global perceived effects rated by caregivers [63, 67]. There is ‘insufficient’ research to conclude the effective- ness of spinal manipulation on recurrence of spinal (back and neck) pain, episode length, pain medication use, and quality of life in children and adolescents (Table 5). Table 4 Participant type in included articles Key: I Infants, C Children, A Adolescents. NB: Duplication exists between reviews and studies Study Design I C A I + C C + A I + C + A Unspecified Paediatric Reviews on spinal manipulation 10 1 1 3 5 10 - Reviews on spinal mobilisation 1 - - - - - - RCTS and other studies on spinal manipulation 8 3 1 - 9 - - RCTS and other studies on spinal mobilisation 3 - - 1 - - - Reviews on spinal manipulation and mobilisation - 1 - 1 - 1 1 RCTS and other studies on spinal manipulation and mobilisation - - - 1 - 1 - Page 11 of 24Milne et al. BMC Pediatrics (2022) 22:721 Ta bl e 5 Su m m ar y re su lts o f d es cr ip tiv e sy nt he si s w ith le ve ls o f e vi de nc e st at em en t f or s pi na l M A N IP U LA TI O N to m an ag e pa ed ia tr ic p op ul at io ns w ith a v ar ie ty o f c on di tio ns Co nd iti on s (P op ul at io n) Le ve ls o f E vi de nc e St at em en t A dv er se E ve nt s D oc um en te d in re vi ew s an d st ud ie s in cl ud ed in th e de sc ri pt iv e sy nt he si s Re vi ew s H ig h- Q ua lit y St ud ie s Su m m ar y St at em en t O ri gi na l R ep or t (A ut ho r & Y ea r) A dv er se E ve nt / (P ra ct iti on er Ty pe ) Fu rt he r c ite d by Sp in al M A N IP U LA TI O N A do le sc en t I di op at hi c Sc ol io si s ^ (A IS ) (C &A ) In co nc lu si ve In su ffi ci en t In co nc lu si ve Ro w e (2 00 6) Tw o be ni gn re ac tio ns (n o fu rt he r d et ai l d oc um en te d) (C hi ro pr ac tic ) Th er ou x (2 01 7) [1 07 ] To dd (2 01 5) [1 08 ] A st hm a (C &A ) In co nc lu si ve ST RO N G E vi de nc e of N o Si gn ifi ca nt E ffe ct ST RO N G E vi de nc e of N o Si gn ifi ca nt E ffe ct # A SD ^ (C &A ) In co nc lu si ve - In co nc lu si ve Sp in al (B ac k / N ec k) P ai n ^ (C &A ) (C om bi ne d Ch ro ni c an d Ac ut e Pa in ) In co nc lu si ve In co nc lu si ve In co nc lu si ve *E va ns (2 01 8) U nu su al o r i nc re as ed s or en es s (5 1% -5 4% ) a nd d iff er en t t yp e of pa in (3 1% -3 4% ) ( C hi ro pr ac tic ) L’E cu ye r ( 19 59 ) N ec k pa in in 1 2- ye ar -o ld g irl w ith a hi st or y of c on ge ni ta l t or tic ol lis , pr og re ss io n to u ns te ad y ga it, po or c oo rd in at io n, d ro w si ne ss , an d ho sp ita lis at io n w ith de la ye d di ag no si s of c on ge ni ta l oc ci pi ta lis at io n. (C hi ro pr ac tic ) G re en (2 02 0) [2 1] Vo hr a (2 00 7) [1 10 ] Zi v (1 98 3) Ba ck p ai n in 1 2- ye ar -o ld g irl w ith h is to ry o f o st eo ge ne si s im pe rf ec ta — pr og re ss iv e ne ur om us cu la r d efi ci ts in le gs , cl on us a t r es t, ur in ar y ur ge nc y an d fre qu en cy , p ar ap le gi a. (C hi ro pr ac tic ) Vo hr a (2 00 7) [1 10 ] Br ea st fe ed in g D iffi cu lti es ^ (I) In co nc lu si ve - In co nc lu si ve C P ^ (I, C , A ) In co nc lu si ve In su ffi ci en t In co nc lu si ve H ea da ch e (C &A ) In su ffi ci en t ST RO N G E vi de nc e of N o Si gn ifi ca nt E ffe ct ST RO N G E vi de nc e of N o Si gn ifi ca nt E ffe ct Bo ru si ak (2 01 0) H ot s ki n an d di zz in es s, tr an si to ry in cr ea se in h ea da ch e in te ns ity an d fre qu en cy a nd lo ss o f co ns ci ou sn es s in b ot h tr ea tm en t se ss io ns ; q ui ck re co ve ry o nc e tr ea tm en t s to pp ed . ( M an ua l th er ap is t) G re en (2 02 0) [2 1] Zi m m er m an (1 97 8) Se ve re o cc ip ita l a nd b ifr on ta l he ad ac he , v om iti ng , l ef t f ac ia l w ea kn es s, di pl op ia a ta xi a. (C hi ro pr ac tic ) Vo hr a (2 00 7) [1 10 ] Page 12 of 24Milne et al. BMC Pediatrics (2022) 22:721 Ta bl e 5 (c on tin ue d) Co nd iti on s (P op ul at io n) Le ve ls o f E vi de nc e St at em en t A dv er se E ve nt s D oc um en te d in re vi ew s an d st ud ie s in cl ud ed in th e de sc ri pt iv e sy nt he si s Re vi ew s H ig h- Q ua lit y St ud ie s Su m m ar y St at em en t O ri gi na l R ep or t (A ut ho r & Y ea r) A dv er se E ve nt / (P ra ct iti on er Ty pe ) Fu rt he r c ite d by H el d (1 96 6) A cu te re sp ira to ry de co m pe ns at io n, tr ac he ot om y, ne ur ol og ic d efi ci ts a t C 6 an d C 7 ve rt eb ra e, n ec k pa in . ( M ed ic al pr ac tit io ne r) Vo hr a (2 00 7) [1 10 ] In fa nt ile C ol ic – c ry in g (I) In co nc lu si ve In co nc lu si ve In co nc lu si ve M ill er (2 01 2) O ne c hi ld in c om pa ris on gr ou p re po rt ed a n A E of in cr ea se d cr yi ng . I nc id en ce o f in cr ea se d cr yi ng in c om pa ris on gr ou p: 2. 94 % (0 .5 2, 1 4. 92 ) (C hi ro pr ac tic ) Co rs o (2 02 0) [7 3] Sh af rir (1 99 2) In th re e of th es e st ud ie s a sm al l nu m be r o f m ild h ar m s w as re po rt ed ; t he o th er tw o st ud ie s (n = 1 45 ) r ep or te d no h ar m s. O ne st ud y (n = 9 56 ) r ep or te d si de eff ec ts o r r ea ct io ns in c hi ld re n af te r c hi ro pr ac tic tr ea tm en t (n = 5 57 ), bu t b ot h si de e ffe ct s or re ac tio ns a nd tr ea tm en t te ch ni qu es w er e no t s pe ci fie d. (C hi ro pr ac tic ) D rie hu is (2 01 9) [2 6] El lw oo d (2 02 0) [1 14 ] In fa nt ile C ol ic ^ – S le ep in g (I) In co nc lu si ve In su ffi ci en t In co nc lu si ve Ko ch (1 99 8) Ve ge ta tiv e re ac tio ns , b ra dy ca rd ia , ta ch yc ar di a, a nd re fle x ap no ea re co rd ed in m or e th an h al f o f pa tie nt s. A lth ou gh a pn oe a w as of s ho rt d ur at io n (< 1 0 s) a nd re ve rs ib le , i t c an b e re ga rd ed as a p ot en tia lly li fe -t hr ea te ni ng ad ve rs e ev en t. N B: C on di tio ns w er e m ix ed (c ol ic , o pi st ot on us , hy pe rt on us , w ry ne ck , pl ag io ce ph al y, s co lio si s, lim b w ea kn es s an d sl ob be rin g) . (C hi ro pr ac tic ) Br an d (2 00 5) [4 1] W ils on (2 01 2) Se ve re : R ib fr ac tu re s (7 th a nd 8 th po st er io r) (C hi ro pr ac tic ) N B: re fe rr al re as on n ot c on fir m ed To dd (2 01 5) [1 08 ] N oc tu rn al E nu re si s (C &A ) VE RY S TR O N G E vi de nc e of N o Si gn ifi ca nt E ffe ct - VE RY S TR O N G E vi de nc e of N o Si gn ifi ca nt E ffe ct Le bo eu f ( 19 91 ) 4 – 15 -y ea r- ol d ch ild re n an d ad ol es ce nt s: Se ve re h ea da ch e, st iff n ec k an d ac ut e lu m ba r sp in e pa in . ( 5th y ea r C hi ro pr ac tic st ud en ts ) G re en (2 02 0) [2 1] Vo hr a (2 00 7) [1 10 ] H aw k (2 00 7) [9 8] G la ze ne r ( 20 05 ) [ 44 ] Page 13 of 24Milne et al. BMC Pediatrics (2022) 22:721 Ta bl e 5 (c on tin ue d) Co nd iti on s (P op ul at io n) Le ve ls o f E vi de nc e St at em en t A dv er se E ve nt s D oc um en te d in re vi ew s an d st ud ie s in cl ud ed in th e de sc ri pt iv e sy nt he si s Re vi ew s H ig h- Q ua lit y St ud ie s Su m m ar y St at em en t O ri gi na l R ep or t (A ut ho r & Y ea r) A dv er se E ve nt / (P ra ct iti on er Ty pe ) Fu rt he r c ite d by O tit is M ed ia ^ (I & C ) In co nc lu si ve In su ffi ci en t In co nc lu si ve Sa w ye r ( 19 99 ) 6- m on th s to 6 y ea rs — M id -b ac k so re ne ss a nd in cr ea se d irr ita bi lit y (A ca de m ic C hi ro pr ac to rs ) G re en (2 02 0) [2 1] Co rs o (2 02 0) [7 3] Vo hr a (2 00 7) [1 10 ] H aw k (2 00 7) [9 8] Po hl m an (2 01 2) [1 05 ] G la ze ne r ( 20 05 ) [ 44 ] To rt ic ol lis ^ (I & C ) In su ffi ci en t In su ffi ci en t In su ffi ci en t Ja co bi (2 00 1) Su ba ra ch no id h ae m or rh ag e an d de at h of 3 -m on th -o ld g irl (p re se nt in g co nd iti on u nc le ar ) (P hy si ot he ra pi st ) G re en (2 02 0) [2 1] Vo hr a (2 00 7) [1 10 ] El lw oo d (2 02 0) [2 7] D rie hu is (2 01 9) [2 6] Br an d (2 00 5) [4 1] Sh af rir (1 99 2) Q ua dr ip le gi a in 4 -m on th - ol d bo y, s ec on da ry to s pi na l co rd a st ro cy to m a; re gr es se d to p ar ap le gi a (1 8 m on th s po st op er at iv el y) . ( C hi ro pr ac tic ) To dd (2 01 5) [1 08 ] D rie hu is (2 01 9) [2 6] El lw oo d (2 02 0) [2 7] A ll fin di ng s pr es en te d in th is ta bl e ar e a re su lt of th e de sc rip tiv e sy nt he si s pr es en te d in S up pl em en ta ry F ile 5 H ig h qu al ity e vi de nc e w as n ot a va ila bl e to e xp lo re th e eff ec tiv en es s of s pi na l m an ip ul at io n on in di vi du al s w ith th e fo llo w in g co nd iti on s: A tt en tio n D efi ci t H yp er ac tiv ity D is or de r ( A D H D ), dy sf un ct io na l v oi di ng , K IS S sy nd ro m e, u pp er c er vi ca l d ys fu nc tio n Po pu la tio ns : I – In fa nt s, C – Ch ild re n, A – A do le sc en ts # A st hm a— sp in al m an ip ul at io n on p ae di at ric p op ul at io ns h ad ‘n o si gn ifi ca nt e ffe ct ’ o n pu lm on ar y fu nc tio n an d fin di ng s w er e in co nc lu si ve fo r p ea k  ex pi ra to ry fl ow , g en er al a st hm a sy m pt om s, se ve rit y le ve ls a nd q ua lit y of li fe ^ A dd iti on al h ig h- qu al ity re se ar ch (e .g ., RC Ts ) m ay b e w ar ra nt ed A ll ad ve rs e ev en ts e xt ra ct ed fr om in cl ud ed s ys te m at ic re vi ew s, ex ce pt th os e st ud ie s m ar ke d w ith * w hi ch h av e be en e xt ra ct ed fr om in di vi du al s tu di es In su ffi ci en t: In su ffi ci en t h ig h- qu al ity e vi de nc e av ai la bl e on th e to pi c an d fu rt he r r es ea rc h m ay b e w ar ra nt ed In co nc lu si ve : A va ila bl e ev id en ce is in co nc lu si ve , a nd fu rt he r r es ea rc h m ay b e w ar ra nt ed N o Si gn ifi ca nt E ffe ct : H ig h- qu al ity e vi de nc e su gg es ts th e in te rv en tio n is n ot e ffe ct iv e an d sh ou ld n ot b e us ed in c lin ic al p ra ct ic e Si gn ifi ca nt P os iti ve E ffe ct : H ig h- qu al ity e vi de nc e su gg es ts th e in te rv en tio n is e ffe ct iv e an d co ul d be u se d w he n cl in ic al re as on in g su pp or ts it s ap pl ic at io n Page 14 of 24Milne et al. BMC Pediatrics (2022) 22:721 There is also ‘insufficient’ research to conclude if spinal manipulation is effective for managing paediatric popula- tions presenting with chronic (only) spinal pain or acute (only) spinal pain. Consequently, our descriptive synthesis of the collective evidence suggests the effectiveness of spinal manipulation for managing spinal (back and neck) pain in paediatric populations remains ‘inconclusive’. Breastfeeding difficulties Of the four reviews [28, 30, 99, 104], two suggested there was favourable findings for the use of spinal manipulative therapy of infants with breast- feeding difficulties, however, one of these was a low level (Level 3b) review [99] and the other reviews [28, 104] did not support these findings. No additional studies were included on this topic. Our  descriptive synthesis sug- gests that the evidence for using spinal manipulation in infants to improve breastfeeding outcomes is ‘inconclusive’ (Table 5). Cerebral palsy (CP) Two reviews [25, 104] explored the use of spinal manipulation in children for manag- ing a variety of impairments associated with CP and both determined there was inconclusive evidence for its effectiveness. Whilst a single RCT with 78 participants [74] provides evidence of significant desirable effects for spinal manipulation in children and adolescents for reducing spasticity in wrist muscles, our descriptive syn- thesis  suggests ‘inconclusive’ findings regarding the effec- tiveness of spinal manipulation to manage impairments of CP in children (Table 5). Dysfunctional voiding Whilst two reviews [25, 104] which investigated osteopathic manipulative therapy for improving symptoms related to dysfunctional void- ing in children, were captured in the present scoping review, neither met the requirements for inclusion in the descriptive synthesis as each review only included one study on the topic. Additionally, no individual stud- ies were captured, therefore a descriptive synthesis on this topic could not be undertaken (Table 5). Headache A single systematic review exploring the effectiveness of spinal manipulation for improving impairments related to headache in children and ado- lescents [104], was included and indicated inconclu- sive results. Two included RCTs [52, 77] have explored the effects of spinal manipulation across six different outcomes related to headache in children and adoles- cents. Whilst one large (n = 194) RCT [77] found spinal manipulation significantly reduced the number of days with headache and significantly enhanced the global perceived effect from parents, the collective included evidence exploring the effects of spinal manipulation demonstrated no significant changes to the duration of headache, days of school missed due to headache, con- sumption of analgesics or intensity of headache (see Supplementary File 5). Subsequently our descriptive syn- thesis of the collective research revealed there is strong evi- dence that spinal manipulation has ‘no significant effec- tive’ on headache (Table 5). Infantile colic From the twelve reviews [1, 21, 25, 26, 42, 43, 66, 91, 96, 98, 103, 104] that explored the effects of spinal manipulation for managing crying / behaviour related impairments of infantile colic, four [42, 66, 96, 98] demonstrated significant positive results in infants for reducing crying time and improved symptoms. However, all other reviews demonstrated no significant effect, neg- ative effects, or inconclusive findings (see Supplementary File 5). Two additional RCT’s [58, 92] and two other stud- ies [68, 71] showed significant positive effects for reduc- ing crying time and later symptoms as a toddler, with other RCTs [85, 92] and studies [53, 71] demonstrating no significant effects from spinal manipulation in infants (see Supplementary File 5). Four reviews [42, 66, 91, 104] explored the effects of spinal manipulation for improving sleep time for infants with colic and all found inconclu- sive results, except Dobson [42] who found significant improvements. One additional RCT captured in our review [58] showed significant improvements in sleep time from spinal manipulation in infants with colic. Con- sequently, our descriptive synthesis revealed ‘inconclusive’ findings for the effectiveness of spinal manipulation to manage infantile colic for both crying time and sleep dis- turbances (Table 5). Nocturnal enuresis Five reviews [26, 44, 46, 96, 98] explored the use of spinal manipulation in children and adolescents to improve symptoms associated with noc- turnal enuresis. Most found that there was no significant effect, with one review [26] finding inconclusive results. No additional studies were captured in our descriptive synthesis. Our descriptive synthesis  suggests that there is very strong evidence of ‘no significant effect’ from spinal manipulation for managing symptoms of nocturnal enu- resis in children and adolescents (Table 5). Otitis media Three reviews [98, 104, 105] that met our requirements for inclusion in the descriptive synthesis investigated the effects of spinal manipulation in infants to improve symptoms associated with otitis media. One [98] found no significant effects and two reviews [104, 105] found inconclusive results. A small cohort study [81] showed a significant reduction in otitis media symp- toms (temperature and redness and bulging appear- ance of tympanic membrane) in children post spinal Page 15 of 24Milne et al. BMC Pediatrics (2022) 22:721 manipulation with a hand held pressure applicator but their findings have not been replicated. One further study [78] explored the use of spinal manipulation for improv- ing otitis media-related symptoms in infants, however as it was a feasibility study for a larger RCT, the analysis of between group results was not reported. Our descriptive synthesis reveals ‘inconclusive’ findings with no strong evi- dence to support the use of spinal manipulation to man- age otitis media (Table 5). Torticollis One review [62] exploring the use of spinal manipulation in infants and children met our criteria for descriptive synthesis. This review explored the effects of spinal manipulation on eight different outcomes related to torticollis, revealing inconclusive findings for each outcome. A single study [70] was also included in our descriptive synthesis and showed that lateral flexion and head righting reactions were not significantly improved after treatment involving spinal manipulation. Subse- quently, our descriptive synthesis  suggests ‘insufficient’ findings with no clear evidence to support the use of spinal manipulation in infants to manage impairments related to torticollis (Table 5). High quality evidence was not available to explore the effectiveness of spinal manipulation for KISS syndrome or upper cervical dysfunction. Effects of spinal mobilisation in infants, children and adolescents Four systematic reviews [25–27, 104] explored the effects of spinal mobilisation on paediatric populations to manage impairments related to asthma [26], ADHD [25], torticollis [27] and upper cervical dysfunction [104]. Three of the four reviews were included in the descriptive synthesis as only one study was reviewed on the topic of interest (upper cervical dysfunction) for Parnell, 2019, which meant that it was precluded from our descriptive synthesis. Four additional studies [60, 75, 80, 81] were also captured in the present scoping review, exploring the effects of spinal mobilisation on infants and children with infantile colic, otitis media, plagiocephaly (without torticollis) and upper cervical dysfunction respectively (Supplementary File 5). Asthma With only one review [26] included and show- ing inconclusive results for the use of spinal mobilisation to improve peak expiratory flow in children and adoles- cents with asthma, our descriptive synthesis suggests that there is ‘insufficient’ evidence to make conclusions regard- ing the effectiveness of spinal mobilisation for managing asthma symptoms. (Table 6). ADHD A single systematic review [25] met our criteria for descriptive synthesis which explored the use of spi- nal mobilisation to improve outcomes for children with ADHD using the Connors Scale. No significant effects were found, and as there were no additional studies exploring the effects of spinal mobilisation on children with ADHD, our descriptive synthesis reveals ‘insufficient’ evidence to draw conclusions regarding the use of spinal mobilisation for managing ADHD. (Table 6). Infantile colic A single RCT [80] explored the effects of spinal mobilisation on crying time in infants with colic, showing positive effects in the medium term (8–10 days) but no significant effectives in the short term (0–6 days). Our descriptive synthesis  revealed ‘insufficient’ evidence to draw conclusions regarding the use of spinal mobilisa- tion to improve infantile colic. (Table 6). Torticollis A single systematic review [27] met our criteria for descriptive synthesis which explored the effectiveness of spinal mobilisation for improving cer- vical mobility and cranial symmetry using the Argenta scale with infants. Both outcomes were reported to be improved by spinal mobilisations in infants with torticol- lis. However, as there are no additional reviews or studies on the topic, our descriptive synthesis reveals ‘insufficient’ evidence to draw conclusions regarding the use of spinal mobilisation to improve impairments associated with tor- ticollis in infants. (Table 6). Plagiocephaly (without torticollis) and upper cervical dys- function A single RCT [60] revealed that spinal mobili- sation of the neck may reduce treatment days for infants with plagiocephaly but had no significant effects on motor development. Further, a single low level (Level III-2) study [75], suggested that spinal mobilisation of the neck may improve active and spontaneous movement of the neck in infants with upper cervical dysfunction. Our descrip- tive synthesis suggests that there is ‘insufficient’ evidence to draw conclusions regarding the use of spinal mobilisation with infants and children to improve outcomes related to plagiocephaly (without torticollis) or upper cervical dys- function. (Table 6). Adverse events associated with spinal manipulation and mobilisation For both reviews and studies included in the present scoping review, there was limited reporting of adverse events which means the true incidence is unknown. Of the reviews and studies that did report on adverse events related to spinal manipulation and mobilisation of Page 16 of 24Milne et al. BMC Pediatrics (2022) 22:721 infants, children and adolescents, they varied from mild to severe in nature (Table 7). Table 7 provides a summary of the reporting behaviours from included articles and demonstrates that six systematic reviews, eight RCTs and five other studies did not report the adverse events asso- ciated with using spinal manipulation to manage paedi- atric populations for a variety of conditions. Six reviews and three RCTs reported that there were no adverse events from using spinal manipulation with paediatric populations. When adverse events were documented, the trend demonstrated in the RCT’s were mild, transitory pain or soreness. All adverse events have been extracted from the original articles and documented in Tables  5 and 6 beside the conditions being treated at the time of the adverse events. Most adverse events were associated with spinal manipulation, rather than mobilisation and most occurred in infants or children, with few noted in adolescent populations. Policies, regulations, position statements, practice guidelines and opinion papers Ten policy and policy development statements [2, 22, 95, 115–121] were included in this systematic scoping review. Most were from the United States of America with three of seven policies from Australia [2, 69, 95]. Two policies recommended the use of spinal manipulation in infants, Table 6 Summary results of descriptive synthesis with levels of evidence statement for spinal MOBILISATION to manage paediatric populations with a variety of conditions All findings presented in this table are a result of the descriptive synthesis presented in Supplementary File 5 High quality evidence was not available to explore the effectiveness of spinal mobilisation on individuals with the following conditions: adolescent idiopathic scoliosis (AIS), autism spectrum disorder (ASD), back/neck pain, breastfeeding difficulties, cerebral palsy (CP), dysfunctional voiding, headache, infantile colic, KISS syndrome, nocturnal enuresis Populations: I – Infants, C – Children, A – Adolescents All adverse events extracted from included systematic reviews, except those studies marked with * which have been extracted from individual studies. ^Additional high-quality research (e.g., RCTs) may be warranted Insufficient: Insufficient high-quality evidence available on the topic and further research may be warranted Inconclusive: Available evidence is inconclusive, and further research may be warranted No Significant Effect: High-quality evidence suggests the intervention is not effective and should not be used in clinical practice Significant Positive Effect: High-quality evidence suggests the intervention is effective and could be used when clinical reasoning supports its application Conditions (Population) Levels of Evidence Statement Adverse Events Documented in reviews and studies included in the descriptive synthesis Reviews High-Quality Studies Summary Statement Original Report (Author & Year) Adverse Event / (Practitioner Type) Further cited by Spinal MOBILISATION Asthma ^ (C&A) Insufficient - Insufficient ADHD ^ (C) Insufficient - Insufficient Otitis Media ^ (I&C) - Insufficient Insufficient Torticollis ^ (I) Insufficient - Insufficient Plagiocephaly ^ (I) (With no torticollis) - Insufficient Insufficient Upper Cervical Dysfunction ^ (I) - Insufficient Insufficient Saedt (2018) Mild: back soreness, irritability, poor feeding, mild distress, increased crying, increased head tilt, temporary vegetative responses after mobilisation including: - Flushing: 17.8% (14.03, 22.59) - Hyper-extension: 4.3% (2.49, 7.11) - Perspiration: 3.6% (2.01, 6.30) - Gastro-esophageal reflux: 0.3% (0.06, 1.82) - Short breathing pattern changes: 9.2% (6.39, 12.87) Corso (2020) [73] Page 17 of 24Milne et al. BMC Pediatrics (2022) 22:721 children and adolescents [117, 118]. The International Chiropractors Association [118] recommend the earliest possible evaluation, detection and correction (using spi- nal manipulative therapy) in infants to maximise normal growth and development. One policy [117] stated that spinal manipulation must only be performed to manage three conditions: (i) if there has been documented symp- toms involving the spine, (ii) subluxations of the spine are evidenced with corresponding symptoms and therapy has a direct relationship with improving function and (iii) if manipulation is appropriate to restore function that has been compromised by illness or injury. Contrary to above recommendations, seven policies do not recommend the use of spinal manipulation in infants, children and ado- lescents with arguments stating that it is experimental, unproven and not medically necessary [2, 69, 115, 116, 119–121]. Two of these policies specifying age groups, with one stating that spinal manipulation should not be used on paediatric patients under the age of two years [22] and the other not recommending it under the age of 12 years [119]. Of the policies that do not support this form of treatment, most don’t specify the conditions it is not recommended for. In those that do, there is a general trend towards prohibiting use for non-musculoskeletal conditions including ADHD, ASD, asthma, infantile colic, nocturnal enuresis and otitis media. There were 14 text and opinion papers included in this systematic scoping review. Six did not support the use of spinal manipulation in infants, children and adoles- cents with comments suggesting there is limited research Table 7 Adverse event reporting practice of included reviews and studies L1a – Systematic Review of RCTs; L1b – Systematic Review of RCTs and other studies; L2a – Systematic review of quasi-experimental studies, L2b – Systematic review of quasi-experimental and other lower-level studies; L3a – Systematic Review of comparable cohort studies; L3b – Systematic review of comparable cohort and other lower-level studies; L4a – Systematic review of descriptive studies; LII – RCT, LIII-1 – Pseudorandomised controlled trial, LIII-2 – Comparative study with concurrent controls, LIII-3 – Comparative study without concurrent controls Adverse events not reported Nil adverse events reported Adverse events reported Mild Moderate Severe Adverse events associated with spinal manipulation Reviews Alcantara (2015) L2b [55] Ernst (2009) L1a [43] Fairest (2019) L4 [29] Fry (2014) L3 [30] Karpouzis (2010) L3b [101] Kronau (2016) L2b [102] Edwards (2019) L3b [28] Ferrance (2010) L1b [91] Huang (2011) L1a [46] Hondras (2005) L1a [45] Romano (2008) L3b [106] Vaughn (2012) L1b [109] Alcantara (2011a) L1b [48] Carnes (2018) L1b [66] Corso (2020) L1b [73] Gleberzon (2012) L1b [96] Pohlman (2012) L1b [105] Theroux (2017) L1b [107] Vohra (2007) L1b [110] Brand (2005) L1a [41] Glazener (2005) L1a [44] Green (2019) L1b [21] Hawk (2007) L1b [98] Vohra (2007) L1b [110] Brand (2005) L1a [41] Corso (2020) L1b [73] Green (2019) L1b [21] Todd (2015) L1b [108] Vohra (2007) L1b [110] RCT’s Bronfort (2001) LII [56] Browning (2008) LII [58] Dissing (2018) LII [63] Kachmar (2018) SII [74] Lynge (2021) LII [77] Nemett (2008) LII [83] Olafsdottir (2001) LII [85] Reed LII (1994) [87] Miller, Newell & Bolton (2012) LII [80] Selhorst LII (2015) [89] Haugen LII (2011) [70] Balon LII (1998) [49] Borusiak LII (2009) [52] Evans (2018) LII [67] Other studies Davies (2007) LIII-3 [53] Hayden (2003) LIII-3 [57] Lantz (2001) LIII-2 [59] Miller & Newell (2012) LIII-2 [71] Miller (2009) LIII-2 [68] Alcantara (2009) LIII-3 [50] Sawyer (1999) LIII-2 [78] Leboeuf (1991) LIII-3 [61] Adverse events associated with spinal mobilisation Reviews Parnell (2019) L1b (104) Brurberg (2019) L1b [62] Ellwood (2020) L1b [27] Driehuis (2019) L1b [26] Corso (2020) L1b [73] Corso (2020) L1b [73] Corso (2020) L1b [73] RCT’s Cabrera-Martos (2016) LII [60] Other studies Zhang (2004) LSIII-2 [81] Saedt (2018) LIII-2 [75] Page 18 of 24Milne et al. BMC Pediatrics (2022) 22:721 within the area, with no satisfactory evidence, suggest- ing the risks outweigh the potential benefits [65, 69, 84, 88, 90, 93]. Two text and opinion papers suggest there is limited, however, growing evidence for the use of spinal manipulation and report that care should be taken when using this form of treatment for managing impairments in paediatric populations [82, 88]. Conversely, six text and opinion papers support the use of spinal manipula- tion as a form of treatment for paediatric clients [72, 76, 79, 94, 95, 97] arguing that most chiropractors use best practice evidence-based treatment techniques, and that spinal manipulation may be effective in treating the pae- diatric populations. One text and opinion paper stated they are disappointed by the temporary restriction in Australia and believe chiropractors should not be singled out in performing such treatment, with limited evidence of harm [95]. Two guidelines were included in this review, one from Australia and one from the United States of America. The Australian guideline [47] suggested clinicians should not recommend spinal manipulation in infants as evidence is inconclusive. Conversely, the Council of Chiroprac- tic Practice [54] recommendation suggests chiropractic care (inclusive of spinal manipulation) may be indicated at any age group and care must be taken to select the most appropriate treatment technique along with paren- tal education. However, it is important to note that this guideline was published prior to the interim legislation. Discussion The primary aim of this systematic scoping review was to identify and map the available evidence regarding the effectiveness and harms of spinal manipulation and mobilisation of infants, children, and adolescents. Additionally, we aimed to identify and synthesise policies, regulations, position statements and practice guidelines informing the clinical application of spinal manipulation and mobilisation in paediatric populations. In relation to our first aim, this systematic scoping review revealed that spinal manipulation and mobilisation is being utilised clinically by a variety of health professionals to manage paediatric populations with nocturnal enuresis, otitis media, infantile colic, excessive crying, breastfeeding difficulties, headaches, CP, back/neck pain, AIS, ADHD, ASD, torticollis, asthma, KISS syndrome, and dysfunctional voiding. We utilised a levels-of-evidence approach in our descriptive synthesis and whilst some individual high-quality studies demonstrated positive effects from spinal manipulation and mobilisation for some conditions, there is no collective evidence using objective measures to explicitly support the application of spinal manipulation or mobilisation for any condition in paediatric populations, however, adverse events were reported. Our descriptive synthesis revealed very strong evidence that spinal manipulation has no significant effect on nocturnal enuresis. Whilst results from previously published systematic reviews were inconclusive, our descriptive synthesis of studies with high methodological quality suggests there is strong evidence that spinal manipulation has no significant effect on impairments related to asthma (pulmonary function) or headache. The evidence was inconclusive regarding the effectiveness of spinal manipulation for managing impairments related to AIS, ASD, back/ neck pain (acute and chronic) and CP in children and adolescents. Additionally, the evidence was inconclusive regarding the effectiveness of spinal manipulation for managing impairments and symptoms related to breastfeeding difficulties, infantile colic (excessive crying and sleep disturbances), and otitis media in infants and children. There was insufficient evidence to report on the effectiveness of spinal manipulation for infants and children with torticollis and ADHD. Further, there is insufficient evidence to determine the effectiveness of spinal mobilisation on paediatric populations for managing any condition. To further address our first aim, we explored the adverse events/harms associated with spinal manipula- tion and/or mobilisation in paediatric populations. The findings in the present systematic scoping review revealed that there is limited reporting of adverse events in the included systematic reviews and studies, with six reviews, eight RCTs and five other studies making no mention of adverse events or harms associated with their spinal manipulation intervention of focus (Table  7). Although some of these articles were published before 2010, those RCT’s published after 2010, have failed to comply with the internationally accepted updated CONSORT guidelines which urges authors to be completely transparent in their reporting of harms [122]. Four systematic reviews focused specifically on adverse events and harms associated with treatment of infants, children and adolescents involving spinal manipulation and mobilisations and revealed that adverse events ranged from mild – requiring self or par- ent care only, to severe – for example, death. All adverse events that were extracted from our included articles are documented in the data extraction table (Supplemen- tary File 3) and these have been summarised according to the conditions being managed in the studies/reviews reporting adverse events (Tables 5 and 6). With respect to potential harms, our review identified under-reporting of adverse events across both reviews and studies (Table 7), impacting our ability to draw firm conclusions regard- ing the safety of spinal manipulation and mobilisation in infants, children and adolescents and this finding aligns with conclusions expressed in previous reviews [21, 26]. Page 19 of 24Milne et al. BMC Pediatrics (2022) 22:721 Due to the limited reporting of adverse events in many studies, the true incidence remains unknown [104, 110]. However, we would like to highlight that although there have been some reports (studies and reviews) demon- strating improvement in mild transient adverse symp- toms (e.g., muscle soreness and tightness [21, 44, 73, 105, 110], anxiety [44] and increased crying [73] after receiving treatment with spinal manipulation), there has also been reports of more serious adverse events such as severe headache [21, 52, 108, 110], loss of consciousness [21, 52, 110], poor coordination and unsteady gait [110], clonus at rest [110], reflex apnoea [41], facial weakness [108], diplo- pia ataxia [108], acute respiratory decompensation [110] and urinary urgency and frequency [110]. Whilst most adverse events are mild and transient, the most severe adverse events from spinal manipulation noted in the literature are progressive neuromuscular deficits lead- ing to quadriplegia (later improving to paraplegia post- surgically), missed or delayed diagnoses (e.g., spinal cord astrocytoma and congenital occipitalisation), subarach- noid haemorrhage and death. (Table  5). Related to this issue, it is evident that there is an important difference in the practice of clinical reasoning for spinal manipu- lation across the professions, with some advocating for using a directional ‘thrust’ to move a spinal segment back into alignment (i.e., adjustment) [5] and some pro- fessions using a HVLA passive thrust to the spinal joint within its anatomical limit [6]. Whilst the research team were able to confirm ‘spinal manipulation’ as the treat- ment technique in this review during study selection, very little detail was given to describe the way the spinal segment or joint was being manipulated. Future publi- cations regarding spinal manipulation should explicitly describe the form of manipulation being undertaken, as it is entirely possible that the effectiveness and safety could vary between techniques. Whilst the prevalence of documented adverse events from spinal manipulation and mobilisation appears to be relatively low, the most severe adverse events were reported in infants during treatment of conditions where it is difficult to monitor the structures being impacted due to the small anatomi- cal size of infants and where there are other effective evidence-based intervention options (e.g., torticollis [27] infantile colic [114]). Notably, there were less adverse events reported for spinal mobilisation in paediatric populations, with one review article [73] identifying severe adverse events such as rib fractures and missed significant diagnoses (e.g., spinal cord astrocytoma), however, our scoping review also identified far less stud- ies or reviews exploring the use of spinal mobilisation (as opposed to spinal manipulation) in paediatric popula- tions from which to extract this data. Most studies within the included reviews came from low levels of evidence such as case studies or case series, which were not included as individual studies for our cur- rent systematic scoping review as we felt they were too low in the levels of evidence hierarchy to provide addi- tional meaningful results regarding effectiveness. The inclusion of adverse events extracted from lower levels of research published in the included systematic reviews, has provided important safety related information for readers to consider. However, since most of the literature is based on low-level studies such as case reports, it is not safe to assume that their conclusions can be generalised to larger or alternate populations. Health professionals would benefit from further training, either as graduates or in entry-level programs, to better understand levels of evidence to assist with interpretation of research, to inform their choice of treatment techniques and to guide design of future research, should they choose to do it. Consistent with the lower levels of evidence and meth- odological quality of studies, it was noted that very few studies reported on the clinometric properties of the outcome measures utilised, and we recommend future research on this topic to include references regarding the reliability, validity, utility, and efficacy of outcome meas- ures used to explore effectiveness and to improve cred- ibility of study findings. Healthcare professionals and researchers should be aware of the reliability, validity, and responsiveness of assessment tools and outcome meas- ures to assist in their clinical reasoning, instrument selec- tion and interpretation of clinical or research results. Further evaluation of these factors must be completed in future research to assist with interpretation of the collec- tive findings on this important topic. Regarding our final aim, we have identified that most policy and policy development statements included in this systematic scoping review were developed in the United States of America, many by third party payers, and only three published in Australia. This highlights the need for more policies globally across all professions who are performing spinal manipulation and mobilisation with paediatric populations. Evidence-based guidelines and policy or position statements are needed to guide health professionals on the appropriateness of spinal manipulation and mobilisation to manage a variety of conditions for which paediatric clients commonly present for care. This is particularly important considering our comprehensive review and descriptive synthesis did not determine spinal manipulation or mobilisation to be effective for treating any condition examined (Tables  5 and 6), albeit with limited research to examine for spinal mobilisation. Whilst not captured by our inclusion criteria (due to being published in Dutch language), the Netherlands have produced four factsheets [123–126] Page 20 of 24Milne et al. BMC Pediatrics (2022) 22:721 on diagnostics and therapeutics in infants (0–1 year) and children (1–18 years) to guide physiotherapy practice for using manual therapy in paediatric populations, and their guidance is congruent with the findings of the present scoping review. The findings from the present systematic scoping review align with the findings from the previous work by Green [21] for the Safer Care Victoria report on Chiropractic spinal manipulation of children under 12: Independent review [2] and the recent findings from Cote and colleagues [14]. Green (2019) [21] explored the effectiveness and safety of spinal manipulation (but not mobilisation) in children under 12  years for any condition or impairment, irrespective of the profession providing treatment. The outcome of Greens’ review was that spinal manipulation should not (due to a lack of evidence and potential risk of harm) be recommended for management of paediatric clients with; headache, asthma, otitis media, cerebral palsy, hyperactivity disorders or torticollis, however, they suggested that there may be some (although unlikely) benefits of spinal manipulation in the management of infantile colic and nocturnal enuresis. The findings from the present systematic scoping review differ slightly as our descriptive synthesis using a levels of evidence approach, extends these conclusions as we also found very strong evidence that spinal manipulation is not effective for managing nocturnal enuresis. Further, we found the evidence to be ‘inconclusive’ for managing excessive crying and sleep in infants with infantile colic. Our findings, much like those of Cote [14] suggest that evidence is lacking to support the use of spinal manipulative therapy to treat non-musculoskeletal disorders, undermining the validity of the theory that spinal manipulation has physiological effects on the organs and their function. The findings from the present systematic scoping review add to the Safer Care Victoria review in the following ways: (i) exploring both spinal manipulation and mobilisation; (ii) inclusion of paediatric patients up to the age of 18 years; (iii) inclusion of various study designs except individual case reports and case studies; (iv) investigated policies, guidelines and laws supporting or prohibiting the use of spinal manipulation or mobilisation. It should be noted that many of the policies identified in this scoping review from the USA were reimbursement policies and there remains a need in the USA for professional associations to establish position statements and treatment guidelines. A challenge that we faced in screening, appraising, data extracting and synthesising the included articles, was the lack of detailed descriptions of therapeutic techniques being applied (i.e., spinal manipulation and mobilisation techniques) on infants, children and adolescents; a concern raised in a previous review on the topic [26]. Relevant and necessary information regarding the treatment technique used were often not clearly stated. Due to the underreporting of specific techniques, we had to exclude numerous reviews on the basis that we were uncertain of the treatment technique being applied. Consequently, this has limited our ability to draw conclusions regarding effectiveness of specific treatment techniques, particularly spinal mobilisation. These findings align with the findings of other reviews who also highlight the importance of increasing the methodological quality to describe intervention techniques completed by the practitioner [26, 104]. To assist with capturing a wider sample of studies in future reviews, it would be beneficial for researchers to include details describing the exact treatment technique, the number and duration of treatments patients received, and the healthcare providers experience and training. A strength of this systematic scoping review includes the wide breadth of searches undertaken. Several major databases were searched with a detailed search strategy and with a broad, yet specific inclusion criteria to ensure the scope of existing literature was included. Hand searching of reference lists for all included studies and reviews was undertaken to ensure all relevant literature was captured for this systematic scoping review. The study selection, data extraction process and critical appraisal was completed independently by two reviewers to reduce the risk of reviewer error or bias and a third reviewer was utilised to validate data extraction and provide consensus for critical appraisal. Our review sets itself apart from previous research by focusing on both spinal manipulation and mobilisation, as well as including participants from birth to 18  years of age. Exclusion of individual case studies and case reports allowed for conclusions to be based on higher levels of evidence and this was particularly important when the collective evidence from systematic reviews were inconclusive. Due to the inclusion of systematic reviews, there were several primary studies included more than once, potentially leading to overrepresentation of individual studies, which may have biased the interpretation of the results. Whilst we independently descriptively synthesised the individual study outcomes (from high quality studies); the synthesis findings may have been influenced by one study population or methods if they had completed multiple investigations, and therefore, one population sample may have biased our analysis. On the occasion that this was likely (n = 2 conditions), we have highlighted this to the reader (see Supplementary File 5). As there was limited overlap and because many reviews included low levels of evidence, data extraction, critical appraisal and descriptive synthesis was completed for both the studies and the reviews Page 21 of 24Milne et al. BMC Pediatrics (2022) 22:721 independently before applying the levels of evidence approach to our descriptive synthesis. The overarching limitation of our findings is the high representation of non-RCT (e.g., observational studies, case studies) in the included reviews, leaving in some cases our synthesis and conclusions to be based on the collective findings from lower levels of evidence. A further limitation of this scoping review is the use of a descriptive synthesis employing a levels of evidence approach based on quality and quantity of studies without consideration of sample size, rather than a meta-analysis which meant we were unable to determine effect sizes. Despite the current limitations, this systematic scoping review provides information to build awareness regarding the available evidence for safety and effectiveness of spinal manipulation and mobilisation in paediatric populations (birth up to 18  years) and these findings can be used to guide more impairment focused quantitative analysis in future meta-analyses. The results of this systematic scop- ing review will also help to inform the future development of a shared position statement between the IFOMPT and IOPTP to guide clinical practice. Conclusions The present systematic scoping review revealed spinal manipulation and mobilisation are utilised clinically by a variety of health professionals to manage many different musculoskeletal and non-musculoskeletal impairments for paediatric populations. A broad descriptive synthe- sis of the collective evidence (using a levels-of-evidence approach) did not demonstrate evidence to explicitly sup- port spinal manipulation or mobilisation as an effective intervention for any condition in paediatric populations with mild to severe adverse events reported. Strong to very strong evidence exists to suggest that spinal manipulation is not effective for managing asthma, headache or noctur- nal enuresis whereas, there was inconclusive or insufficient evidence for all other conditions explored. There is insuf- ficient evidence to determine the effectiveness of spinal mobilisation for treating paediatric populations with any condition, with some mild adverse responses reported. Despite spinal manipulation and mobilisation being used to treat infants, children, and adolescents internationally, there is a lack of conclusive high-level evidence providing positive (i.e., favourable) results with paediatric popula- tions. More high-level clinically reasoned RCT’s, express- ing the magnitude of effect from spinal manipulation and mobilisation are needed, to further allow exploration of the safety and effectiveness of these interventions with infants, children and adolescents, for further conclu- sions to be drawn. Future research should include strict monitoring and recording of adverse events to determine true risks and could start with small long term RCTs. If evidence was accumulating for a given condition, a large multicentre RCT would be beneficial. In addition, future research in this field, should provide detailed information about the therapeutic technique, the clinical reasoning, and theoretical underpinnings for its use, particularly in non-musculoskeletal conditions. Currently most research informing the results of this systematic scoping review are based on chiropractic interventions. Research regarding physiotherapy methods for mobilisation and manipulation for some conditions (e.g., back and neck pain/stiffness) in older children and adolescents is warranted as it remains a gap in the literature. Supplementary Information The online version contains supplementary material available at https:// doi. org/ 10. 1186/ s12887- 022- 03781-6. Additional file 1: Supplementary File 1. Search Strategy Additional file 2: Supplementary File 2. Critical Appraisal Consensus Scores Additional file 3: Supplementary File 3. Data Extraction Additional file 4: Supplementary File 4. Matrix with RCT’s and other studies included across all systematicreviews Additional file 5: Supplementary File 5. Descriptive Synthesis Acknowledgements Not applicable Authors’ contributions NM: Stakeholder engagement, project conceptualisation, study design and planning methodology including search terms, consensus for screening and critical appraisal, synthesis / analysis of results, supervision and editing of manuscript writing, submission to journal. LL: Planning methodology including search terms, independent screening and critical appraisal, synthesis / analysis of results, writing and editing of manuscript writing. AP: Planning methodology including search terms, independent screening and critical appraisal, synthesis / analysis of results, writing and editing of manuscript writing. JP: Stakeholder engagement, project conceptualisation, study design and planning methodology including search terms, editing of manuscript writing. KO: Stakeholder engagement, project conceptualisation, study design and planning methodology including search terms, editing of manuscript writing. AB: Stakeholder engagement, project conceptualisation, study design and planning methodology including search terms, editing of manuscript writing. AG: Stakeholder engagement, project conceptualisation, study design and planning methodology including search terms, editing of manuscript writing. The author(s) read and approved the final manuscript. Funding Funding was obtained after the completion of the scoping review to support Open Access Publication. Article Processing Charges were jointly funded by the International Federation of Orthopaedic Manipulative Physical Therapists [IFOMPT] and International Organisation of Physical Therapists in Paediatrics [IOPTP]. Availability of data and materials All data generated or analysed during this study are tabulated in this published article [and its supplementary information files]. Declarations Ethics approval and consent to participate Not applicable. https://doi.org/10.1186/s12887-022-03781-6 https://doi.org/10.1186/s12887-022-03781-6 Page 22 of 24Milne et al. BMC Pediatrics (2022) 22:721 Consent for publication Not applicable. Competing interests The authors declare they have no competing interests. Author details 1 Department of Physiotherapy, Faculty of Health Sciences and Medicine, Bond University, Queensland, Australia. 2 International Organisation of Physiotherapists in Paediatrics, World Physiotherapy Subgroup, Queensland, Australia. 3 Research Group Lifestyle and Health, Institute of Human Movement Studies, University of Applied Sciences, Utrecht, The Netherlands. 4 International Federation of Orthopaedic Manipulative Physical Therapy and Northern Rehab Physical Therapy Specialists, Anchorage, USA. 5 University of Witwatersrand, Johannesburg, South Africa. 6 McMaster University, Hamilton, Canada. Received: 9 November 2021 Accepted: 28 November 2022 References 1. Bronfort G, Haas M, Evans R, Leininger B, Triano J. Effectiveness of manual therapies: the UK evidence report. Chiropr Osteopat. 2010;18:3. 2. Safer Care Victoria. Chiropractic spinal manipulation of children under 12- Independent review Melbourne2019. [Available from: https:// www. bette rsafe rcare. vic. gov. au/ sites/ defau lt/ files/ 2019- 10/ 20191 024- Final% 20Chi ropra ctic% 20Spi nal% 20Man ipula tion. pdf. 3. IFOMPT (International Federation of Orthopaedic Manipulative Physi- cal Therapists). Educational standards in orthopaedic manipulative therapy- Part A. 2016. 4. Australian Capital Territory. Health Practitioner Regulation National Law (ACT). 2020. 5. International Chiropractors Association. ICA Policy Statement on Spinal Adjustment and Spinal Manipulation 2017 [1]. Available from: https:// www. chiro pract ic. org/ wp- conte nt/ uploa ds/ 2021/ 05/ The- ICA- Policy- State ment- on- Spinal- Adjus tment- and- Spinal- Manip ulati on. pdf. 6. International Federation of Orthopaedic Manipulative Physical Thera- pists (IFOMPT). Educational Standards in Orthopaedic Manipulative Therapy Part A: Educational Standards. 2016 [Available from: https:// www. ifompt. org/ site/ ifompt/ IFOMPT% 20Sta ndards% 20Doc ument% 20defi niti ve% 202016. pdf. 7. World Health Organisation. WHO guidelines on basic training and safety in chiropractic. 2005 Guideline. 8. National Center for Complementary and Integrative Health. Spinal Manipulation: What you need to know 2019 [Available from: https:// www. nccih. nih. gov/ health/ spinal- manip ulati on- what- you- need- to- know. 9. Canadian Chiropractic Association (CCA). Education and the Countrolled Act of Spinal Manipulation 2020 [Available from: https:// chiro pract ic. ca/ about- cca/ code- of- ethics/ educa tion- contr olled- act- spinal- manip ulati on/. 10. No place for spinal manipulation in infant care [press release]. 2019. 11. Bussières AE, Al Zoubi F, Stuber K, French SD, Boruff J, Corrigan J, et al. Evidence-based practice, research utilization, and knowledge transla- tion in chiropractic: a scoping review. BMC Complement Altern Med. 2016;16(1):1–15. 12. Leboeuf-Yde C, Innes SI, Young KJ, Kawchuk GN, Hartvigsen J. Chiro- practic, one big unhappy family: better together or apart? Chiropr Man Ther. 2019;27(1):1–8. 13. Schneider MJ, Evans R, Haas M, Leach M, Hawk C, Long C, et al. US chiropractors’ attitudes, skills and use of evidence-based practice: a cross-sectional national survey. Chiropr Man Ther. 2015;23(1):1–12. 14. Côté P, Hartvigsen J, Axén I, Leboeuf-Yde C, Corso M, Shearer H, et al. The global summit on the efficacy and effectiveness of spinal manipu- lative therapy for the prevention and treatment of non-musculoskel- etal disorders: a systematic review of the literature. Chiropr Man Ther. 2021;29(1):1–23. 15. Gatterman MI. Foundations of chiropractic: subluxation: Elsevier Health Sciences; 2005. 16. Hannon S. Objective physiologic changes and associated health benefits of chiropractic adjustments in asymptomatic subjects: a review of the literature. Journal of Vertebral Subluxation Research. 2004:1–9. 17. McDonald WP, Durkin KF, Pfefer M, editors. How chiropractors think and practice: the survey of North American chiropractors. Seminars in Integrative Medicine; 2004: Elsevier. 18. Russell D. The assessment and correction of vertebral subluxation is central to chiropractic practice: is there a gap in the clinical evidence? J Contemp Chiropr. 2019;2:4–17. 19. Picchiottino M, Leboeuf-Yde C, Gagey O, Hallman DM. The acute effects of joint manipulative techniques on markers