Open Access
Obstetrics/Gynecology and Pediatrics  |   January 2021
Pilot study assessing the effect of osteopathic manipulative treatment (OMT) on length of stay in neonates after therapeutic hypothermia
Author Affiliations & Notes
  • Kira Bendixen, DO
    Bristol Bay Area Health Corporation, Dillingham, AK, USA
  • Alexis Beinlich, DO
    Departments of Internal Medicine and Pediatrics, Maine Medical Center, Portland, ME, USA
  • Bryan Beck, DO
    Hospital Manipulation Service, Maine Medical Center, Portland, ME, USA
  • Nabeel Hashmi, MS IV
    Tufts University School of Medicine, Boston, MA, USA
  • Alexa Craig, MD
    Tufts University School of Medicine, Boston, MA, USA
  • Corresponding author: Kira Bendixen, DO, Bristol Bay Area Health Corporation, P.O. Box 130, Dillingham, AK 99576-0130, USA, E-mail: drkirado@gmail.com  
Article Information
Osteopathic Manipulative Treatment / Pediatrics
Obstetrics/Gynecology and Pediatrics   |   January 2021
Pilot study assessing the effect of osteopathic manipulative treatment (OMT) on length of stay in neonates after therapeutic hypothermia
The Journal of the American Osteopathic Association, January 2021, Vol. 121, 97-104. doi:https://doi.org/10.1515/jom-2020-0005
The Journal of the American Osteopathic Association, January 2021, Vol. 121, 97-104. doi:https://doi.org/10.1515/jom-2020-0005
Abstract

Context: Term neonates treated with therapeutic hypothermia (TH) may experience delays in acquiring skills for oral feeding, thus prolonging hospital admission.

Objective: To determine whether osteopathic manipulative treatment (OMT) can decrease the overall length of stay (LOS) for term neonates by accelerating the transition to full oral feeds.

Methods: A pilot study was conducted to compare LOS in term neonates treated with OMT to matched historical controls. Eligibility criteria were gestational age greater than or equal to 37 weeks, mild to moderate encephalopathy, absent seizure activity, and no brain injury on magnetic resonance imaging. Treated neonates had OMT twice between day of life four and seven, then twice per week on nonconsecutive days until hospital discharge. Secondary outcomes were to compare the number of days with nasogastric tube in both OMT and historically matched control groups and to characterize somatic dysfunction patterns in the primary affected areas of the craniosacral mechanism.

Results: Twelve of 28 neonates treated with TH between October 2017 and August 2018 met eligibility criteria for the study and were matched 3:1 to 36 historical controls. On average, mothers of neonates who received OMT were older than the historical control mothers (31.3 years [SD, ±6.0] vs. 27.4 [SD, ±4.5]; p=0.02) Nineteen of the 36 historical control neonates, but no neonates in the OMT group, were intubated for a median of two days (interquartile range 1, 4). The mean LOS in the OMT group was 9.1 vs. 11.6 days for historical controls (p=0.048); however, in a sensitivity analysis excluding intubated neonates from the historical controls, the difference was 9.1 vs. 10.1 days (p=0.21). All neonates were orally feeding at discharge. Neonates given OMT had between two and four treatments lasting 8–20 minutes. By the final treatment, the craniosacral mechanism’s intraosseous and cranial base compressions and physiologic motion were improved. There were no adverse effects noted during OMT sessions.

Conclusion: Our findings suggest that OMT performed on term neonates treated with TH may decrease the amount of time needed to acquire the necessary skills for oral feeding. Although this result was not statistically significant, it may be clinically significant. A larger prospective clinical trial may have the power needed to detect a statistically significant reduction in LOS and number of days to full oral feeds in this patient population.

Roughly two to five per 1,000 births are affected by neonatal encephalopathy (NE); this term describes abnormal neurologic examination features in a neonate in the first days of life related to hypoxia and ischemia around the time of birth. 1 The current standard of care for neonates with NE is to initiate a neuroprotective therapy, therapeutic hypothermia (TH), within the first six hours of life to increase chances of survival and preserve neurodevelopment. 2, 3, 4, 5 TH is achieved by cooling the neonate to 33–34 °C for 72 hours, followed by a gradual period of rewarming over more than 12 hours. During this time, neonates are not fed enterally because of concern for potential decreased gut perfusion and associated complications. 6 As such, a barrier to hospital discharge for these neonates is a successful transition from nasogastric (NG) feeds to either breast or bottle feeding. In neonates without brain injury on magnetic resonance imaging (MRI), hospitalization is often briefly extended to allow the neonate to develop the skills necessary to achieve full oral feeding before discharge. For neonates with brain injury, depending on the severity, these skills may take much longer to develop, or may never be acquired, resulting in need for percutaneous endoscopic gastrostomy tube placement. 
Osteopathic manipulative treatment (OMT) helps to effectively stabilize and regulate the autonomic nervous system 7 and the cranial nerves that are important in sucking and latching reflexes, which, in turn, facilitates the acquisition of skills necessary for oral feeding. 8, 9 Additionally, the neonatal cranium is strikingly malleable at this age, with the occipital bone comprising four parts and the sphenoid and temporal bones each comprising three parts. This increase in mobility results in increased susceptibility to developing intraosseous compressions when subjected to the forces of a normal labor and delivery process. 8 Traumatic deliveries that require interventions such as vacuum extraction, forceps, or maneuvers for shoulder dystocia can exacerbate or add additional strain to the forces of normal labor, which potentially increases the risk of these intraosseous compressions. 8 Previous studies 10, 11 have demonstrated that OMT can improve oral feeding skills and decrease risk for gastrointestinal dysfunction in premature neonates, leading to a mean reduction of six days in the hospital length of stay (LOS). A relationship between craniosacral strain patterns and the associated symptoms (e.g., poor latch, poor suck, vomiting, hyperactive peristalsis, tremor, hypertonicity, and irritability) has been shown to affect the nervous, circulatory, and respiratory systems, as evidenced by difficult or irregular respirations, excessive mucus, and marked cyanosis. 8 In this study, we hypothesized that term neonates treated with therapeutic hypothermia (TH) would be able to accelerate the transition to full oral feeds through the application of OMT, thus decreasing their overall LOS. We also hypothesized that these neonates would demonstrate improved somatic dysfunction patterns through decreased prevalence of nonphysiologic strain patterns within the craniosacral mechanism. 
Methods
This investigation was designed as a pilot study of neonates treated with TH to assess LOS in a prospectively recruited group treated with OMT. These neonates were compared with matched, historical controls who were not treated with OMT. Written informed consent was obtained from a parent before enrollment in the OMT group. The study was reviewed and approved by the Maine Medical Center’s institutional review board in Portland, Maine, and was registered with clinicaltrials.gov (NCT03380013). 
Selection and description of participants
Eligible neonates were born at least 37 weeks in gestational age, diagnosed with mild to moderate neonatal encephalopathy, 12 treated with TH, had no seizure activity, and had a normal brain MRI. Specific additional exclusion criteria were as follows: neonates affected by neonatal abstinence syndrome, intrauterine growth restriction, those with major congenital anomalies (e.g., cleft palate), a prenatal history of maternal diabetes, or a moribund status (i.e., neonates unlikely to benefit from aggressive life support). These inclusion and exclusion criteria were carefully selected to minimize factors that increased time for neonates to develop oral feeding skills. Each patient was then matched to three historical controls from an existing institutional database by a research assistant (N.H.) who was blinded to all information about historical controls except for the following matching criteria: neonate sex, gestational age by completed week, degree of encephalopathy, absence of seizures, and normal MRI. 
Outcome measure
The primary outcome measure was a comparison of total hospital LOS in OMT managed neonates vs. historical controls. LOS was determined based on the date of birth (same as the date of admission) and date of discharge and was counted in full days. 
Two secondary outcomes were investigated. One secondary outcome measure compared the number of days to full oral feeds between study groups and was assessed by analyzing the number of days a neonate required a nasogastric (NG) tube for feeding. This data was extracted from the intake and output documentation in the electronic health record (EHR) of each patient’s chart. Full oral feeding volume was defined as a 24-hour period in which the NG tube was not used; this time frame was selected to avoid confounding from smaller increments that could be attributable to nursing care or other factors not related to OMT. 
The other secondary outcome measure was the identification of somatic dysfunction patterns through documented findings on the osteopathic structural examination (OSE) performed before and after OMT. A qualitative analysis of patterns specific to the craniosacral mechanism was completed using these data. 
Patients were identified for enrollment by the principal investigator (A.C.), a neonatal neurologist who was actively involved in the clinical care of each of these patients. The PI was responsible for determining eligibility and obtaining informed consent during the period of TH, after confirmation of a normal brain MRI. TH was carried out per the current standard of care according to existing clinical guidelines and was not part of this investigation. OMT was provided after TH was complete at no charge to the patient, insurance, or any other third-party payer. OMT was performed by one of three selected providers (K.B., A.B., B.B.). Patients were not compensated for participation. 
OMT protocol
Two OMT sessions were performed between fourth and seventh day of life. For neonates who were hospitalized longer, OMT was continued twice per week on nonconsecutive days until the neonate was discharged. Each neonate was evaluated with an OSE before each treatment, which included examination of the head, cervical, thoracic, lumbar, sacral, pelvic, and rib cage regions for underlying somatic dysfunctions. Subjective comments were noted from parents or nursing staff. The OSE findings and subjective comments were then documented at each OMT encounter (Appendix). Specific OMT techniques were used at each provider’s discretion and included a combination of myofascial release, balanced ligamentous tension, balanced membranous tension, and osteopathic cranial manipulative medicine. Per current standard protocol, neonates ingested nothing by mouth throughout TH and started on NG tube feeds after completion of TH. 
Statistical analysis
Baseline differences between the OMT and historical controls were compared using χ2 tests or Fisher exact tests, as appropriate, for categorical variables and t tests or their nonparametric equivalents for continuous variables. Nonparametric variables were presented as medians and interquartile ranges. The primary analysis compared LOS for neonates in the OMT group to the historical controls. In the secondary analysis, the number of days for the neonates to achieve full oral feeding was compared. Lastly, an additional secondary analysis compared the somatic dysfunction patterns within the craniosacral mechanism of neonates before and after receiving OMT. 
A power calculation demonstrated that a two-group t test with p value of 0.05 would have 80% power to detect the difference between the OMT group mean of 7.3 days and the historical controls mean of 11.5 days. The difference in means was 4.2 days, assuming that the expected standard deviation is 4.4 when the sample sizes in the OMT group or the historical controls are 12 and 36, respectively. 
Results
From October 2017 to August 2018, 28 neonates were treated with TH, and 12 were included in this study (Figure 1). Potential patients were excluded based on severe encephalopathy, gestational age less than 37 weeks, and maternal gestational diabetes. Following the completion of recruitment and OMT sessions, 36 matched historical controls were extracted from the existing TH database. On average, mothers of neonates who received OMT were older than the historical control mothers (31.3 years [standard deviation, SD, ±6.0] vs. 27.4 [SD, ±4.5]; p=0.02), but did not significantly differ in cesarean section rate or frequency of other delivery complications (Table 1). There were no significant differences in gestational age, weight, Apgar scores, or umbilical cord gases. Notably, neonates in the OMT group were never intubated, but 19 out of 36 (52.7%) of historical controls had been intubated for a median of two days (p=0.01). 
Figure 1:
Flow diagram of participants’ progress through the study.
Figure 1:
Flow diagram of participants’ progress through the study.
Table 1:
Clinical characteristics of mothers and neonates.a
Characteristics Received OMT n=12 Historical controls n=36 p-value
Maternal characteristics
 Mean maternal age, years (SD) 31.3 (6.0) 27.4 (4.5) 0.02
 Vacuum assistance, n (%) 2 (16.6%) 6 (16.7%) 1.0
 Shoulder dystocia, n (%) 2 (16.6%) 8 (22.2%) 1.0
 Cesarean section, n (%) 4 (33.3%) 15 (41.7%) 0.9
Neonate characteristics
 Female sex, n (%) 4 (33.3%) 13 (36.1%) 1.0
 Mean birth weight, kg (SD) 3.3 (0.7) 3.5 (0.5) 0.5
 Mean gestational age, weeks (SD) 39.5 (1.0) 39.8 (1.3) 0.5
 Median Apgar Score 1 minute (IQR) 2 (2, 4) 2 (2, 3) 0.7
 Median Apgar Score 5 min (IQR) 5 (5, 7) 4 (4, 6) 0.2
 Median Apgar Score 10 min (IQR) 7 (6, 9) 6 (5, 7) 0.09
Cord gases
 Mean arterial pH (SD) 7.08 (0.12) 7.08 (0.17) 0.9
 Mean arterial base deficit (SD) −11.5 (4.6) −11.7 (5.8) 0.9
 Mean venous pH (SD) 7.23 (0.08) 7.17 (0.19) 0.3
 Mean venous base deficit (SD) −8.1 (3.5) −11.7 (4.9) 0.1
Respiratory support
 Intubated, n (%) 0 (0%) 19 (52.7%) 0.01
 Median days ventilated (IQR)b N/A 2 (1, 4) N/A
aData is presented as mean and standard deviation (SD) unless specified as median with interquartile range (IQR) for nonparametric data. bTime ventilated was rounded up to nearest day. kg, kilograms; N/A, not applicable.
Table 1:
Clinical characteristics of mothers and neonates.a
Characteristics Received OMT n=12 Historical controls n=36 p-value
Maternal characteristics
 Mean maternal age, years (SD) 31.3 (6.0) 27.4 (4.5) 0.02
 Vacuum assistance, n (%) 2 (16.6%) 6 (16.7%) 1.0
 Shoulder dystocia, n (%) 2 (16.6%) 8 (22.2%) 1.0
 Cesarean section, n (%) 4 (33.3%) 15 (41.7%) 0.9
Neonate characteristics
 Female sex, n (%) 4 (33.3%) 13 (36.1%) 1.0
 Mean birth weight, kg (SD) 3.3 (0.7) 3.5 (0.5) 0.5
 Mean gestational age, weeks (SD) 39.5 (1.0) 39.8 (1.3) 0.5
 Median Apgar Score 1 minute (IQR) 2 (2, 4) 2 (2, 3) 0.7
 Median Apgar Score 5 min (IQR) 5 (5, 7) 4 (4, 6) 0.2
 Median Apgar Score 10 min (IQR) 7 (6, 9) 6 (5, 7) 0.09
Cord gases
 Mean arterial pH (SD) 7.08 (0.12) 7.08 (0.17) 0.9
 Mean arterial base deficit (SD) −11.5 (4.6) −11.7 (5.8) 0.9
 Mean venous pH (SD) 7.23 (0.08) 7.17 (0.19) 0.3
 Mean venous base deficit (SD) −8.1 (3.5) −11.7 (4.9) 0.1
Respiratory support
 Intubated, n (%) 0 (0%) 19 (52.7%) 0.01
 Median days ventilated (IQR)b N/A 2 (1, 4) N/A
aData is presented as mean and standard deviation (SD) unless specified as median with interquartile range (IQR) for nonparametric data. bTime ventilated was rounded up to nearest day. kg, kilograms; N/A, not applicable.
×
The primary outcome showed that the mean LOS was 9.1 days for the OMT group vs. 11.6 days for the historical controls (p=0.20), a difference of 2.5 days (Table 2). Because intubated neonates typically develop oral feeding skills later, a sensitivity analysis was performed in which the historical controls who were intubated were excluded. The difference in LOS was no longer significant in this analysis, at 9.1 days for the OMT group vs. 10.1 days for the historical controls (p=0.21). 
Table 2:
Primary and secondary outcomes.
Outcome Received OMT n=12 Historical controlsa n=36 p-value
Primary
 Mean length of stay, days (SD) 9.1 (2.0) 11.6 (6.7) 0.20
 Mean length of stay, days (SD) (excluding intubated neonates) 9.1 (2.0) 10.1 (2.3) 0.21
Secondary
 Orally feeding on discharge, n/n (%) 12/12 (100%) 32/32b (100%) 1.00
 Median days with nasogastric tube (IQR) 2.5 (1, 4.3) 2.5 (0, 5) NS
 Mode of feeding at discharge
  Bottle feeding, n (%) 7 (58.3%) 19 (59.3%) NS
  Breastfeeding, n (%) 2 (16.7%) 8 (25%) NS
  Both, n (%) 3 (25%) 5 (15.6%) NS
aDuration of nasogastric tube feeding available for four neonates in the historical control group. bNo duration of nasogastric tube feeding available for four infants in the historical control group. IQR, interquartile range; NS, not significant.
Table 2:
Primary and secondary outcomes.
Outcome Received OMT n=12 Historical controlsa n=36 p-value
Primary
 Mean length of stay, days (SD) 9.1 (2.0) 11.6 (6.7) 0.20
 Mean length of stay, days (SD) (excluding intubated neonates) 9.1 (2.0) 10.1 (2.3) 0.21
Secondary
 Orally feeding on discharge, n/n (%) 12/12 (100%) 32/32b (100%) 1.00
 Median days with nasogastric tube (IQR) 2.5 (1, 4.3) 2.5 (0, 5) NS
 Mode of feeding at discharge
  Bottle feeding, n (%) 7 (58.3%) 19 (59.3%) NS
  Breastfeeding, n (%) 2 (16.7%) 8 (25%) NS
  Both, n (%) 3 (25%) 5 (15.6%) NS
aDuration of nasogastric tube feeding available for four neonates in the historical control group. bNo duration of nasogastric tube feeding available for four infants in the historical control group. IQR, interquartile range; NS, not significant.
×
The secondary outcome assessment of oral feeding skills demonstrated that neonates in the OMT group had a median NG tube duration use of 2.5 days, which was the same as the 32 historical controls for whom NG feeding data were available (Table 2). Data concerning NG tube duration use were not available for four historical controls who were transferred to other institutions for care. All neonates in the OMT group and the 32 historical controls were orally feeding at hospital discharge (Table 2). 
The neonates in the OMT group had between two and four treatments lasting between 8 and 20 minutes (Table 3B). Of these, four neonates (33.3%) were treated twice, five (41.7%) were treated three times, and three (25%) were treated four times. Analysis of the first OSE showed intraosseous occipital compressions lateralized to the right for six of 11 (54.5%) and to the left for one (9.1%). Four (36.4%) of the 11 OMT treated neonates were compressed bilaterally. Within the temporal region, the prevalence of intraosseous compression showed that four (36.4%) were right-sided and seven (63.6%) left-sided. Of the sphenobasilar synchondrosis (SBS) patterns that demonstrated physiologic strain patterns with maintained primary respiratory motion, we found that six (50%) were in extension and two (16.7%) had a torsion (Table 3B). Nonphysiologic SBS compressions with impeded motion of the primary respiratory mechanism were noted on four of 11 (36.4%) initial OSEs; no vertical or lateral strains were observed. Sacral somatic dysfunctions showed a prevalence of nine (75%) extended, one (8.3%) flexed, and two (16.7%) superior on the left. During subsequent treatment, similar patterns were observed in the prevalence of intraosseous occipital and temporal compressions and sacral dysfunctions; however, the prevalence of SBS strain patterns improved towards more physiologic craniosacral strain patterns. Eleven (91.7%) of the neonates treated with OMT had normal physiologic strain patterns identified at the SBS, whereas only eight (66.7%) had normal physiologic strains identified initially (Table 3A). 
Table 3A:
Overall incidence of craniosacral strain patterns observed prior to first and final treatments.
Treatment number Occiput Temporal Sphenobasilar synchondrosis Sacrum
First treatment (n=12) 100% with compression (n=11)a 100% with compression (n=11)a 67% with normal physiology strain pattern (n=8) 0% with full normal sacral motion (n=0)
Final treatment (n=12) 92% with compression (n=11) 83% with compression (n=10) 92% with normal physiologic strain pattern (n=11) 8% with full normal sacral motion (n=1)
aOne of the OMT treated neonates had a blank Occiput section completed on initial OSE; thus, sample size equals n of 11 instead of 12.
Table 3A:
Overall incidence of craniosacral strain patterns observed prior to first and final treatments.
Treatment number Occiput Temporal Sphenobasilar synchondrosis Sacrum
First treatment (n=12) 100% with compression (n=11)a 100% with compression (n=11)a 67% with normal physiology strain pattern (n=8) 0% with full normal sacral motion (n=0)
Final treatment (n=12) 92% with compression (n=11) 83% with compression (n=10) 92% with normal physiologic strain pattern (n=11) 8% with full normal sacral motion (n=1)
aOne of the OMT treated neonates had a blank Occiput section completed on initial OSE; thus, sample size equals n of 11 instead of 12.
×
Similarly, when looking at the OSE prior to the fourth and final treatment, which was performed in only three of the 12 (25%) OMT study neonates, the prevalence of intraosseous occipital and temporal compression remained relatively unchanged, and the prevalence of dysfunction within the sacral region. Most notably, the nonphysiologic SBS strain patterns were resolved and there was free and full primary respiratory motion present at the SBS in two of three (66.7%) of the neonates after the fourth treatment. 
Subjectively, comments collected from parents or nursing staff suggested that the study neonates appeared to continue to have noticeable improvements in feeding after osteopathic treatments (Table 3B). 
Table 3B:
Prevalence of observed craniosacral strain patterns and treatment responses.
Craniosacral strain pattern Total craniosacral strain pattern occurrence per treatmenta Subjective comments by nursing and parents
Treatment #1b n (%) Treatment #2b n (%) Treatment #3c n (%) Treatment #4d n (%)
Occipital n=11 n=12 n=8 n=3 – Seemed better with breastfeeding. Subjectively with mild narrow latch.
– Ready to feed after treatments; fed vigorously.
– Progressive improvement with feeding. Vigorous feed 1 day prior to discharge.
– Taking all PO 2 days prior to discharge.
– Breastfeeding well 1 day prior to discharge.
– Well with breast and bottle. Peaceful with OMT.
– Taking all PO by bottle at 7 days of life.
– Bottle fed, then went to breast on treatment day 4.
– Taking breast and bottle great. Treatment day 3 was day of discharge.
Right compression 6 (54.5%) 7 (58.3%) 4 (50.0%) 2 (66.7%)
Left compression 1 (9.1%) 2 (16.7%) 2 (25.0%) 0
Bilateral compression 4 (36.4%) 2 (16.7%) 1 (12.5%) 1 (33.3%)
Free 0 1 (8.3%) 1 (12.5%) 0
Temporal n=11 n=11 n=8 n=3
Right compression 4 (36.7%) 4 (36.4%) 3 (37.5%) 2 (66.7%)
Left compression 7 (63.6%) 4 (36.4%) 3 (37.5%) 1 (33.3%)
Bilateral compression 0 2 (18.2%) 1 (12.5%) 0
Free 0 1 (9.1%) 1 (12.5%) 0
Sphenobasilar synchondrosis n=12 n=11 n=8 n=3
Flexion 0 0 2 (25.0%) 0
Extension 6 (50.0%) 7 (63.6%) 1 (12.5%) 1 (33.3%)
Torsion 2 (16.7%) 1 (9.1%) 0 0
Sidebending rotation 0 0 0 0
Vertical/lateral 0 0 0 0
Compression 4 (33.3%) 2 (18.2%) 3 (37.5%) 0
Free 0 1 (9.1%) 2 (25.0%) 2 (66.7%)
Sacral n=12 n=12 n=8 n=3
Superior on the left 2 (16.7%) 0 0 0
Superior on the right 0 0 1 (12.5%) 0
Flexion 1 (8.3%) 1 (8.3%) 0 0
Extension 9 (75.0%) 8 (66.7%) 7 (87.5%) 2 (66.7%)
Rotation between the ilia 0 2 (16.7%) 0 1 (33.3%)
Free 0 1 (8.3%) 0 0
aPercentages were calculated by dividing the number of infants with the given strain pattern who received OMT (some had more than one strain pattern present) by the total occurrence of all strain patterns observed for each specific treatment number. b Four neonates required only two OMT treatments prior to discharge. c Five neonates required only three OMT treatments prior to discharge. d Three neonates required only four OMT treatments prior to discharge AA. PO, by mouth.
Table 3B:
Prevalence of observed craniosacral strain patterns and treatment responses.
Craniosacral strain pattern Total craniosacral strain pattern occurrence per treatmenta Subjective comments by nursing and parents
Treatment #1b n (%) Treatment #2b n (%) Treatment #3c n (%) Treatment #4d n (%)
Occipital n=11 n=12 n=8 n=3 – Seemed better with breastfeeding. Subjectively with mild narrow latch.
– Ready to feed after treatments; fed vigorously.
– Progressive improvement with feeding. Vigorous feed 1 day prior to discharge.
– Taking all PO 2 days prior to discharge.
– Breastfeeding well 1 day prior to discharge.
– Well with breast and bottle. Peaceful with OMT.
– Taking all PO by bottle at 7 days of life.
– Bottle fed, then went to breast on treatment day 4.
– Taking breast and bottle great. Treatment day 3 was day of discharge.
Right compression 6 (54.5%) 7 (58.3%) 4 (50.0%) 2 (66.7%)
Left compression 1 (9.1%) 2 (16.7%) 2 (25.0%) 0
Bilateral compression 4 (36.4%) 2 (16.7%) 1 (12.5%) 1 (33.3%)
Free 0 1 (8.3%) 1 (12.5%) 0
Temporal n=11 n=11 n=8 n=3
Right compression 4 (36.7%) 4 (36.4%) 3 (37.5%) 2 (66.7%)
Left compression 7 (63.6%) 4 (36.4%) 3 (37.5%) 1 (33.3%)
Bilateral compression 0 2 (18.2%) 1 (12.5%) 0
Free 0 1 (9.1%) 1 (12.5%) 0
Sphenobasilar synchondrosis n=12 n=11 n=8 n=3
Flexion 0 0 2 (25.0%) 0
Extension 6 (50.0%) 7 (63.6%) 1 (12.5%) 1 (33.3%)
Torsion 2 (16.7%) 1 (9.1%) 0 0
Sidebending rotation 0 0 0 0
Vertical/lateral 0 0 0 0
Compression 4 (33.3%) 2 (18.2%) 3 (37.5%) 0
Free 0 1 (9.1%) 2 (25.0%) 2 (66.7%)
Sacral n=12 n=12 n=8 n=3
Superior on the left 2 (16.7%) 0 0 0
Superior on the right 0 0 1 (12.5%) 0
Flexion 1 (8.3%) 1 (8.3%) 0 0
Extension 9 (75.0%) 8 (66.7%) 7 (87.5%) 2 (66.7%)
Rotation between the ilia 0 2 (16.7%) 0 1 (33.3%)
Free 0 1 (8.3%) 0 0
aPercentages were calculated by dividing the number of infants with the given strain pattern who received OMT (some had more than one strain pattern present) by the total occurrence of all strain patterns observed for each specific treatment number. b Four neonates required only two OMT treatments prior to discharge. c Five neonates required only three OMT treatments prior to discharge. d Three neonates required only four OMT treatments prior to discharge AA. PO, by mouth.
×
Discussion
This pilot study assessed the effect of OMT on hospital LOS and achievement of full oral feedings in term neonates following treatment with TH. The difference in LOS was statistically significant and showed a decrease of 2.5 days for neonates treated with OMT. However, statistical significance was lost in a sensitivity analysis that excluded intubated neonates from the historical control group. These neonates were excluded from this analysis due to the known association between intubation and delayed oral feeding and increased LOS. Although not statistically significant, the OMT group did have a one-day shorter LOS compared with nonintubated historical controls. The TH cohort demonstrated a decrease of one day within the context of an admission that lasted only nine to 12 days. As such, TH neonates had fewer opportunities to receive OMT; therefore, both a larger sample size and a prospectively recruited control group would be required to definitively assess the effect on LOS. Given the potential psychosocial and even financial benefits of shorter hospital LOS, the results of this pilot study suggest a randomized control trial is worth pursuing. 
We analyzed two secondary outcomes: review of days to full oral feeding, measured as full days with NG tube use, and qualitative analysis of craniosacral strain patterns. Analysis of days to full oral feeds showed no statistically significant difference between OMT treated neonates and historical controls. The way this data was collected may have limited our ability to detect a significant difference. Historical control data was collected and documented in 24-hour increments of time, which made it difficult to appreciate improvement in the volume consumed orally from a single feeding to the next. Subjectively, both nurses and parents reported an improvement in oral feeding, and there was an objective improvement appreciated in the craniosacral strain patterns in treated neonates. Transient neuropathies can develop in the nerves responsible for effective latch, suck and swallowing reflexes, such as the vagus, glossopharyngeal or hypoglossal nerves that reside within foramina at the cranial base. 9 These neuropathies commonly are induced into the craniosacral mechanism from the trauma of the labor and delivery process resulting in nonphysiologic strain patterns. 8, 9  
Qualitative analysis of strain patterns was exploratory and performed only on the small sample of the 12 patients who received OMT. Our findings were consistent with those described in previous osteopathic studies conducted in both neonatal patients and healthy adults. 10, 11, 13 One study 8 of 1,250 healthy neonates demonstrated a higher prevalence of physiologic craniosacral strain patterns following a normal and uncomplicated labor and delivery – specifically, torsions and sidebending rotation strains. This study 8 suggested that the strains that are nonphysiologic (compressions, vertical, lateral strains) would be more prevalent following trauma to the system due to disruptions specifically at the cranial base (i.e., following difficult birth). Our pretreatment OSE findings in the 12 neonates in our study support this pattern of increased prevalence of nonphysiologic strain patterns. This finding is consistent with the traumatic birth process these neonates experienced. 
Traumatic births appear to increase the risk of developing nonphysiologic strain patterns, thus inducing transient neuropathies at the cranial base and creating dysfunctions in a neonate’s latch, suck, or swallowing reflexes. The anatomy of the neonatal cranium makes it particularly susceptible to the compressive forces of birth. Specifically, the occipital bone comprises four parts, and the temporal and sphenoid bones comprise three parts. This anatomic fact demonstrates why certain areas have an increased vulnerability for compression. Areas of vulnerability include the hypoglossal canal and the jugular foramen. The hypoglossal canal is formed between the basilar and condylar parts of the occipital bone, which houses the hypoglossal nerve. The jugular foramen is formed where the occiput and temporal bones articulate, which houses the glossopharyngeal, vagus, and accessory nerves. These nervous structures are directly responsible for the functions required for a neonate to feed successfully. 8, 9  
Only a small percentage (one; 8.3%) of the neonates in the OMT group in this study still demonstrated evidence of nonphysiologic strain at the time of discharge, suggesting a beneficial effect from the OMT intervention. Future studies could investigate the differences in underlying pathophysiology that contribute to prolonged neuropathies and, in turn, difficulties or delays in progression to full oral feeds. 
The main limitation of this study was the unintended confounding variables resulting from historically matched controls - specifically, that more than half of the control patients were intubated. While this significant issue was addressed through a sensitivity analysis, statistical significance was lost in part due to reduced sample size. Additionally, OMT was not performed in a manner that permitted nurses and parents to be blinded and may have contributed to overly positive subjective reports of feeding improvement. For this small, unfunded pilot study, there were insufficient resources for an optimal randomized control trial in which parents and nurses could be blinded to treatment status. Finally, there are limitations in the extrapolation of the osteopathic data because multiple osteopathic physicians diagnosed and treated the neonates, which may have created interobserver variation in the reported findings. However, multiple providers found similar craniosacral strain patterns within each patient, suggesting that these observations may in fact be a true representation, albeit one limited by a small sample size. 
The current study highlighted the second and third osteopathic tenets by demonstrating the body’s inherent ability for self-healing and self-regulating and the importance of the interconnectedness of structure and function, respectively. Our OSE findings suggest that increased stress and strain introduced into the craniosacral mechanism during birth in neonates subsequently treated with TH increases the prevalence of nonphysiologic strain patterns and reduction in the primary respiratory mechanism, specifically at the cranial base. This intraosseous compression alters the normal physiologic strain pattern, thus transiently inhibiting the nerves responsible for effective latch, suck, and swallowing reflexes. OMT directed at decompression of the cranial base can effectively target these strains and improved primary respiratory motion and restoration of function. 
Conclusion
Our findings suggest that OMT performed on term neonates treated with TH may decrease the amount of time needed to acquire the necessary skills for oral feeding. Additionally, analysis of OSE data revealed somatic dysfunction patterns consistent with those previously described in neonates following mechanical birth trauma. Specifically, the presence of nonphysiologic strain patterns suggested difficulties in achieving full oral feeds. We demonstrated a qualitative decrease in the overall amount of nonphysiological strain patterns present in the craniosacral mechanism by the time of discharge. 
Acknowledgements
The authors thank the families who participated in OMT treatments. 
  Research funding: Dr. Craig’s protected time for this study was supported by the National Center for Advancing Translational Sciences, National Institutes of Health, Grant No. KL2TR001063.
 
  Informed Consent: Written informed consent was obtained from a parent for neonates enrolled in the OMT group in this study.
 
  Ethical approval: This study was reviewed and approved by the Maine Medical Center’s Institutional Review Board in Portland, Maine. This study was registered with clinicaltrials.gov (NCT03380013).
 
  Author contributions: All authors provided substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data; Drs Bendixen, Beinlich, and Craig drafted the article or revised it critically for important intellectual content; all authors gave final approval of the version of the article to be published; and all authors agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
 
  Competing interests: Authors state no conflict of interest.
 
References
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Shankaran, S, Laptook, AR, Ehrenkranz, RA, et al. Whole-body hypothermia for neonates with hypoxic-ischemic encephalopathy. N Engl J Med. 2005;353(15):1574-1584. https://doi.org/10.1056/nejmcps050929
Azzopardi, D, Brocklehurst, P, Edwards, D, et al. The TOBY Study. Whole body hypothermia for the treatment of perinatal asphyxial encephalopathy: a randomised controlled trial. BMC Pediatr. 2008;8:17. https://doi.org/10.1186/1471-2431-8-17
Shankaran, S, Pappas, A, Laptook, AR, et al. Outcomes of safety and effectiveness in a multicenter randomized, controlled trial of whole-body hypothermia for neonatal hypoxic-ischemic encephalopathy. Pediatrics. 2008;122(4):e791-798. https://doi.org/10.1542/peds.2008-0456
Azzopardi, D, Strohm, B, Edwards, AD, et al. Treatment of asphyxiated newborns with moderate hypothermia in routine clinical practice: how cooling is managed in the UK outside a clinical trial. Arch Dis Child Fetal Neonatal Ed. 2009;94(4):F260-264. https://doi.org/10.1136/adc.2008.146977
Battersby, C, Longford, N, Patel, M, et al. Study protocol: optimising newborn nutrition during and after neonatal therapeutic hypothermia in the United Kingdom: observational study of routinely collected data using propensity matching. BMJ Open. 2018;8(10):e026739. https://doi.org/10.1136/bmjopen-2018-026739
Henley, CE, Ivins, D, Mills, M, Wen, FK, Benjamin, BA. Osteopathic manipulative treatment and its relationship to autonomic nervous system activity as demonstrated by heart rate variability: a repeated measures study. Osteopath Med Prim Care. 2008;2:7. https://doi.org/10.1186/1750-4732-2-7
Frymann, V. Relationship of disturbances of craniosacral mechanism to symptomatology of the newborn: study of 1250 infants. J Am Osteopath Assoc. 1966;65:1059-1075.
Magoun, HI. Entrapment neuropathy of the central nervous system. II. Cranial nerves I-IV, VI-VIII, XII. J Am Osteopath Assoc. 1968;67(7):779-787.
Cerritelli, F, Pizzolorusso, G, Ciardelli, F, et al. Effect of osteopathic manipulative treatment on length of stay in a population of preterm infants: a randomized controlled trial. BMC Pediatr. 2013;13:65. https://doi.org/10.1186/1471-2431-13-65
Pizzolorusso, GTP, Barlafante, G, Cerritelli, F, et al. Effect of osteopathic manipulative treatment on gastrointestinal function and length of stay of preterm infants: an exploratory study. Chiropr Man Ther 2001;19(1):15. https://doi.org/10.1186/2045-709X-19-15
Sarnat, HB, Sarnat, MS. Neonatal encephalopathy following fetal distress. A clinical and electroencephalographic study. Arch Neurol. 1976;33(10):696-705. https://doi.org/10.1001/archneur.1976.00500100030012
Timoshkin, EM, Sandhouse, M. Retrospective study of cranial strain pattern prevalence in a healthy population. J Am Osteopath Assoc. 2008;108(11):652-656.
Osteopathic structural examination reporting form
This form was used by the authors to document findings and subjective comments at each OMT encounter and is reprinted without edits.  
Infant Subject Number: ___________________ 
Date of Treatment: ______________________ 
Day of Life of Infant: _____________________ 
Time Treatment Started: __________________ 
Finished: _________________ 
Name of Treating Physician: _________________________ 
Admission Date: ___________ Discharge Date: __________
Osteopathic structural exam: Craniosacral strain patterns:  
  • Patient Position:
  • Head:
  • Cervical:
  • Thoracic:
  • Lumbar:
  • Sacrum:
  • Pelvis:
  • Rib cage:
 
  • ❑ Occipital 
    • ❑ Right compression
    • ❑ Left compression
    • ❑ Bilateral compression
    • ❑ Free
 
  • ❑ Temporal 
    • ❑ Right restriction
    • ❑ Left restriction
    • ❑ Bilateral restriction
    • ❑ Free
 
  • ❑ Sphenobasilar symphysis (SBS) 
    • ❑ Flexion
    • ❑ Extension
    • ❑ Torsion
    • ❑ Side-bending rotation
    • ❑ Vertical/lateral strain
    • ❑ Compression
    • ❑ Free
Adverse Events: 
  • ❑ No
  • ❑ Yes (please describe):
 
  • ❑ Sacral 
    • ❑ Superior on left
    • ❑ Superior on the right
    • ❑ Flexion
    • ❑ Extension
    • ❑ Rotation between the ilia
    • ❑ Free
(Simple check box for the qualitative collected data on the somatic dysfunction patterns seen in the craniosacral mechanism that would have direct effects on the neurologic, cardiac and respiratory function of these infants.)
Osteopathic structural exam: Craniosacral strain patterns:  
  • Patient Position:
  • Head:
  • Cervical:
  • Thoracic:
  • Lumbar:
  • Sacrum:
  • Pelvis:
  • Rib cage:
 
  • ❑ Occipital 
    • ❑ Right compression
    • ❑ Left compression
    • ❑ Bilateral compression
    • ❑ Free
 
  • ❑ Temporal 
    • ❑ Right restriction
    • ❑ Left restriction
    • ❑ Bilateral restriction
    • ❑ Free
 
  • ❑ Sphenobasilar symphysis (SBS) 
    • ❑ Flexion
    • ❑ Extension
    • ❑ Torsion
    • ❑ Side-bending rotation
    • ❑ Vertical/lateral strain
    • ❑ Compression
    • ❑ Free
Adverse Events: 
  • ❑ No
  • ❑ Yes (please describe):
 
  • ❑ Sacral 
    • ❑ Superior on left
    • ❑ Superior on the right
    • ❑ Flexion
    • ❑ Extension
    • ❑ Rotation between the ilia
    • ❑ Free
(Simple check box for the qualitative collected data on the somatic dysfunction patterns seen in the craniosacral mechanism that would have direct effects on the neurologic, cardiac and respiratory function of these infants.)
×
 
Figure 1:
Flow diagram of participants’ progress through the study.
Figure 1:
Flow diagram of participants’ progress through the study.
Table 1:
Clinical characteristics of mothers and neonates.a
Characteristics Received OMT n=12 Historical controls n=36 p-value
Maternal characteristics
 Mean maternal age, years (SD) 31.3 (6.0) 27.4 (4.5) 0.02
 Vacuum assistance, n (%) 2 (16.6%) 6 (16.7%) 1.0
 Shoulder dystocia, n (%) 2 (16.6%) 8 (22.2%) 1.0
 Cesarean section, n (%) 4 (33.3%) 15 (41.7%) 0.9
Neonate characteristics
 Female sex, n (%) 4 (33.3%) 13 (36.1%) 1.0
 Mean birth weight, kg (SD) 3.3 (0.7) 3.5 (0.5) 0.5
 Mean gestational age, weeks (SD) 39.5 (1.0) 39.8 (1.3) 0.5
 Median Apgar Score 1 minute (IQR) 2 (2, 4) 2 (2, 3) 0.7
 Median Apgar Score 5 min (IQR) 5 (5, 7) 4 (4, 6) 0.2
 Median Apgar Score 10 min (IQR) 7 (6, 9) 6 (5, 7) 0.09
Cord gases
 Mean arterial pH (SD) 7.08 (0.12) 7.08 (0.17) 0.9
 Mean arterial base deficit (SD) −11.5 (4.6) −11.7 (5.8) 0.9
 Mean venous pH (SD) 7.23 (0.08) 7.17 (0.19) 0.3
 Mean venous base deficit (SD) −8.1 (3.5) −11.7 (4.9) 0.1
Respiratory support
 Intubated, n (%) 0 (0%) 19 (52.7%) 0.01
 Median days ventilated (IQR)b N/A 2 (1, 4) N/A
aData is presented as mean and standard deviation (SD) unless specified as median with interquartile range (IQR) for nonparametric data. bTime ventilated was rounded up to nearest day. kg, kilograms; N/A, not applicable.
Table 1:
Clinical characteristics of mothers and neonates.a
Characteristics Received OMT n=12 Historical controls n=36 p-value
Maternal characteristics
 Mean maternal age, years (SD) 31.3 (6.0) 27.4 (4.5) 0.02
 Vacuum assistance, n (%) 2 (16.6%) 6 (16.7%) 1.0
 Shoulder dystocia, n (%) 2 (16.6%) 8 (22.2%) 1.0
 Cesarean section, n (%) 4 (33.3%) 15 (41.7%) 0.9
Neonate characteristics
 Female sex, n (%) 4 (33.3%) 13 (36.1%) 1.0
 Mean birth weight, kg (SD) 3.3 (0.7) 3.5 (0.5) 0.5
 Mean gestational age, weeks (SD) 39.5 (1.0) 39.8 (1.3) 0.5
 Median Apgar Score 1 minute (IQR) 2 (2, 4) 2 (2, 3) 0.7
 Median Apgar Score 5 min (IQR) 5 (5, 7) 4 (4, 6) 0.2
 Median Apgar Score 10 min (IQR) 7 (6, 9) 6 (5, 7) 0.09
Cord gases
 Mean arterial pH (SD) 7.08 (0.12) 7.08 (0.17) 0.9
 Mean arterial base deficit (SD) −11.5 (4.6) −11.7 (5.8) 0.9
 Mean venous pH (SD) 7.23 (0.08) 7.17 (0.19) 0.3
 Mean venous base deficit (SD) −8.1 (3.5) −11.7 (4.9) 0.1
Respiratory support
 Intubated, n (%) 0 (0%) 19 (52.7%) 0.01
 Median days ventilated (IQR)b N/A 2 (1, 4) N/A
aData is presented as mean and standard deviation (SD) unless specified as median with interquartile range (IQR) for nonparametric data. bTime ventilated was rounded up to nearest day. kg, kilograms; N/A, not applicable.
×
Table 2:
Primary and secondary outcomes.
Outcome Received OMT n=12 Historical controlsa n=36 p-value
Primary
 Mean length of stay, days (SD) 9.1 (2.0) 11.6 (6.7) 0.20
 Mean length of stay, days (SD) (excluding intubated neonates) 9.1 (2.0) 10.1 (2.3) 0.21
Secondary
 Orally feeding on discharge, n/n (%) 12/12 (100%) 32/32b (100%) 1.00
 Median days with nasogastric tube (IQR) 2.5 (1, 4.3) 2.5 (0, 5) NS
 Mode of feeding at discharge
  Bottle feeding, n (%) 7 (58.3%) 19 (59.3%) NS
  Breastfeeding, n (%) 2 (16.7%) 8 (25%) NS
  Both, n (%) 3 (25%) 5 (15.6%) NS
aDuration of nasogastric tube feeding available for four neonates in the historical control group. bNo duration of nasogastric tube feeding available for four infants in the historical control group. IQR, interquartile range; NS, not significant.
Table 2:
Primary and secondary outcomes.
Outcome Received OMT n=12 Historical controlsa n=36 p-value
Primary
 Mean length of stay, days (SD) 9.1 (2.0) 11.6 (6.7) 0.20
 Mean length of stay, days (SD) (excluding intubated neonates) 9.1 (2.0) 10.1 (2.3) 0.21
Secondary
 Orally feeding on discharge, n/n (%) 12/12 (100%) 32/32b (100%) 1.00
 Median days with nasogastric tube (IQR) 2.5 (1, 4.3) 2.5 (0, 5) NS
 Mode of feeding at discharge
  Bottle feeding, n (%) 7 (58.3%) 19 (59.3%) NS
  Breastfeeding, n (%) 2 (16.7%) 8 (25%) NS
  Both, n (%) 3 (25%) 5 (15.6%) NS
aDuration of nasogastric tube feeding available for four neonates in the historical control group. bNo duration of nasogastric tube feeding available for four infants in the historical control group. IQR, interquartile range; NS, not significant.
×
Table 3A:
Overall incidence of craniosacral strain patterns observed prior to first and final treatments.
Treatment number Occiput Temporal Sphenobasilar synchondrosis Sacrum
First treatment (n=12) 100% with compression (n=11)a 100% with compression (n=11)a 67% with normal physiology strain pattern (n=8) 0% with full normal sacral motion (n=0)
Final treatment (n=12) 92% with compression (n=11) 83% with compression (n=10) 92% with normal physiologic strain pattern (n=11) 8% with full normal sacral motion (n=1)
aOne of the OMT treated neonates had a blank Occiput section completed on initial OSE; thus, sample size equals n of 11 instead of 12.
Table 3A:
Overall incidence of craniosacral strain patterns observed prior to first and final treatments.
Treatment number Occiput Temporal Sphenobasilar synchondrosis Sacrum
First treatment (n=12) 100% with compression (n=11)a 100% with compression (n=11)a 67% with normal physiology strain pattern (n=8) 0% with full normal sacral motion (n=0)
Final treatment (n=12) 92% with compression (n=11) 83% with compression (n=10) 92% with normal physiologic strain pattern (n=11) 8% with full normal sacral motion (n=1)
aOne of the OMT treated neonates had a blank Occiput section completed on initial OSE; thus, sample size equals n of 11 instead of 12.
×
Table 3B:
Prevalence of observed craniosacral strain patterns and treatment responses.
Craniosacral strain pattern Total craniosacral strain pattern occurrence per treatmenta Subjective comments by nursing and parents
Treatment #1b n (%) Treatment #2b n (%) Treatment #3c n (%) Treatment #4d n (%)
Occipital n=11 n=12 n=8 n=3 – Seemed better with breastfeeding. Subjectively with mild narrow latch.
– Ready to feed after treatments; fed vigorously.
– Progressive improvement with feeding. Vigorous feed 1 day prior to discharge.
– Taking all PO 2 days prior to discharge.
– Breastfeeding well 1 day prior to discharge.
– Well with breast and bottle. Peaceful with OMT.
– Taking all PO by bottle at 7 days of life.
– Bottle fed, then went to breast on treatment day 4.
– Taking breast and bottle great. Treatment day 3 was day of discharge.
Right compression 6 (54.5%) 7 (58.3%) 4 (50.0%) 2 (66.7%)
Left compression 1 (9.1%) 2 (16.7%) 2 (25.0%) 0
Bilateral compression 4 (36.4%) 2 (16.7%) 1 (12.5%) 1 (33.3%)
Free 0 1 (8.3%) 1 (12.5%) 0
Temporal n=11 n=11 n=8 n=3
Right compression 4 (36.7%) 4 (36.4%) 3 (37.5%) 2 (66.7%)
Left compression 7 (63.6%) 4 (36.4%) 3 (37.5%) 1 (33.3%)
Bilateral compression 0 2 (18.2%) 1 (12.5%) 0
Free 0 1 (9.1%) 1 (12.5%) 0
Sphenobasilar synchondrosis n=12 n=11 n=8 n=3
Flexion 0 0 2 (25.0%) 0
Extension 6 (50.0%) 7 (63.6%) 1 (12.5%) 1 (33.3%)
Torsion 2 (16.7%) 1 (9.1%) 0 0
Sidebending rotation 0 0 0 0
Vertical/lateral 0 0 0 0
Compression 4 (33.3%) 2 (18.2%) 3 (37.5%) 0
Free 0 1 (9.1%) 2 (25.0%) 2 (66.7%)
Sacral n=12 n=12 n=8 n=3
Superior on the left 2 (16.7%) 0 0 0
Superior on the right 0 0 1 (12.5%) 0
Flexion 1 (8.3%) 1 (8.3%) 0 0
Extension 9 (75.0%) 8 (66.7%) 7 (87.5%) 2 (66.7%)
Rotation between the ilia 0 2 (16.7%) 0 1 (33.3%)
Free 0 1 (8.3%) 0 0
aPercentages were calculated by dividing the number of infants with the given strain pattern who received OMT (some had more than one strain pattern present) by the total occurrence of all strain patterns observed for each specific treatment number. b Four neonates required only two OMT treatments prior to discharge. c Five neonates required only three OMT treatments prior to discharge. d Three neonates required only four OMT treatments prior to discharge AA. PO, by mouth.
Table 3B:
Prevalence of observed craniosacral strain patterns and treatment responses.
Craniosacral strain pattern Total craniosacral strain pattern occurrence per treatmenta Subjective comments by nursing and parents
Treatment #1b n (%) Treatment #2b n (%) Treatment #3c n (%) Treatment #4d n (%)
Occipital n=11 n=12 n=8 n=3 – Seemed better with breastfeeding. Subjectively with mild narrow latch.
– Ready to feed after treatments; fed vigorously.
– Progressive improvement with feeding. Vigorous feed 1 day prior to discharge.
– Taking all PO 2 days prior to discharge.
– Breastfeeding well 1 day prior to discharge.
– Well with breast and bottle. Peaceful with OMT.
– Taking all PO by bottle at 7 days of life.
– Bottle fed, then went to breast on treatment day 4.
– Taking breast and bottle great. Treatment day 3 was day of discharge.
Right compression 6 (54.5%) 7 (58.3%) 4 (50.0%) 2 (66.7%)
Left compression 1 (9.1%) 2 (16.7%) 2 (25.0%) 0
Bilateral compression 4 (36.4%) 2 (16.7%) 1 (12.5%) 1 (33.3%)
Free 0 1 (8.3%) 1 (12.5%) 0
Temporal n=11 n=11 n=8 n=3
Right compression 4 (36.7%) 4 (36.4%) 3 (37.5%) 2 (66.7%)
Left compression 7 (63.6%) 4 (36.4%) 3 (37.5%) 1 (33.3%)
Bilateral compression 0 2 (18.2%) 1 (12.5%) 0
Free 0 1 (9.1%) 1 (12.5%) 0
Sphenobasilar synchondrosis n=12 n=11 n=8 n=3
Flexion 0 0 2 (25.0%) 0
Extension 6 (50.0%) 7 (63.6%) 1 (12.5%) 1 (33.3%)
Torsion 2 (16.7%) 1 (9.1%) 0 0
Sidebending rotation 0 0 0 0
Vertical/lateral 0 0 0 0
Compression 4 (33.3%) 2 (18.2%) 3 (37.5%) 0
Free 0 1 (9.1%) 2 (25.0%) 2 (66.7%)
Sacral n=12 n=12 n=8 n=3
Superior on the left 2 (16.7%) 0 0 0
Superior on the right 0 0 1 (12.5%) 0
Flexion 1 (8.3%) 1 (8.3%) 0 0
Extension 9 (75.0%) 8 (66.7%) 7 (87.5%) 2 (66.7%)
Rotation between the ilia 0 2 (16.7%) 0 1 (33.3%)
Free 0 1 (8.3%) 0 0
aPercentages were calculated by dividing the number of infants with the given strain pattern who received OMT (some had more than one strain pattern present) by the total occurrence of all strain patterns observed for each specific treatment number. b Four neonates required only two OMT treatments prior to discharge. c Five neonates required only three OMT treatments prior to discharge. d Three neonates required only four OMT treatments prior to discharge AA. PO, by mouth.
×