Newborn OMT Module American College of Osteopathic Pediatricians Robert Hostoffer, DO,FACOP, FAAP edited by Eric Hegybeli, DO, FACOP.

Newborn OMT Module

American College of Osteopathic Pediatricians

Robert Hostoffer, DO,FACOP, FAAP

edited by Eric Hegybeli, DO, FACOP

Background:

Andrew Taylor Still, was born in Virginia in 1828, the son of a Methodist minister and physician. At an early age, Still decided to follow in his father's footsteps as a physician. After studying medicine and serving an apprenticeship under his father, Still became a licensed M.D. in the state of Missouri. Later, in the early 1860's, he completed additional coursework at the College of Physicians and Surgeons in Kansas City, Missouri. He went on to serve as a surgeon in the Union Army during the Civil War.

Background:

After the Civil War and following the death of three of his children from spinal meningitis in 1864, Still concluded that the orthodox medical practices of his day were frequently ineffective, and sometimes harmful. He devoted the next ten years of his life to studying the human body and finding better ways to treat disease.

Background:

His research and clinical observations led him to believe that the musculoskeletal system played a vital role in health and disease and that the body contained all of the elements needed to maintain health, if properly stimulated. Still believed that by correcting problems in the body's structure, through the use of manual techniques now known as osteopathic manipulative treatment, the body's ability to function and to heal itself could be greatly improved. He also promoted the idea of preventive medicine and endorsed the philosophy that physicians should focus on treating the whole patient, rather than just the disease.

http://www.aacom.org/OM/history.html

Osteopathic Tenets (there are 4 main ones)

The body’s inherent ability for self-repair The interrelatedness of body systems The body possesses self-regulatory healing

mechanisms The interrelatedness of structure and

function

Newborn OMT

Review of Structural Basis

Neuroembryology– Neural ridge– Neural tube

Neuroanatomy – Ventricles– Central spinal canal– Choroid plexus– CSF– Cauda equina– Dura mater– Arachnoid villi– Individual cranial bones– Skull

Review Neuroembryology

Neuroembryology– Neural ridge– Neural tube– Dematomal development

Review Neuroanatomy

Review Bones and sutures of the Skull(make note of the difference in angle from horizontal of the cranial base (a line from the eye socket to base of occiput) – it is about 30 degrees in child (more horizontal) and 50 degrees in the adult)

Pediatric Adult

Note differences of adult and infant skull:

Physiological Basis

Blood-brain barrier Primary respiratory mechanism Craniorhythmic impulse Circulation of the CSF Axes of motion in the cranium Axonal transport “The rule of the artery is supreme.” Active labor, transition and delivery

Blood-Brain Barrier

Review CSF circulation

Developmental Relationship Structure↔Function

““Ram’s Horn” ShapeRam’s Horn” Shape Embryologic: CNS grows faster than cranium

Foramina:Foramina: Cranial Bones are in multiple parts at birth (nerves don’t poke through bones)

Suture typesSuture types for motion develop as plates meet

Wolff’s Law:Wolff’s Law: Cartilage is laid down along lines of stress

Osteopathy in the Cranial Field

Cranial Bone Movement Midline: Flexion/Extension

Paired: External/Internal Rotation

ReminderSReminderS

Flexion (Fat Head) Extension (Cone Head)LATERAL SBS Strain (Parallelogram Head)

Common Patterns of Cranial Plagiocephaly

Cranial Somatic DysfunctionAffects Function

Ophthalmologic– CN II, III, IV, VI

Gastrointestinal– CN IX, X, XII

Respiratory– CN X

Musculoskeletal– XI

Parasympathetics with III, VII, IX, X

CN IX - Glossopharyngeal Nerve

Jugular Jugular ForameForame

nn

CN IX - Glossopharyngeal Nerve

Function

Structure Dysfunction

History

Physical examination

Motor to muscle; Parasympathetic to glands; Sensory to palate

Jugular foramen

Difficulties swallowing, excessive gag reflex

Trauma to occiput &/or temporals

Test gag reflex Evaluation of temporals, occiput,

occipitomastoid suture

CN XI - Accessory Nerve

SCMForamen Magnum

CN XII - Hypoglossal Nerve

HypoglossaHypoglossal canall canal

CN XII - Hypoglossal Nerve

Function Structure Dysfunction

History

Physical examination

Motor to Tongue

Hypoglossal canal Dysphagia, tongue function

(latch-suckle) Occipital condyle trauma;

intraosseous strain

Test tongue motions Test neonatal suck Evaluate occiput (condyles),

top cervicals

Prevalent Pediatric Problems

Musculoskeletal System– Scoliosis– Torticollis

Respiratory System– Otitis Media (Acute vs.

Serous)– Pharyngitis– Bronchiolitis– Asthma & Reactive

Airway Disease (RAD)

Gastrointestinal System– Constipation– Poor Feeding/Sucking– GER & GERD

Neuro-Psycho-Social – Learning Disorders

(ADD/ADHD)– Strabismus

Prevalent Pediatric Problems

Musculoskeletal System– Torticollis – Scoliosis

Torticollis = Twisted Neck

Common positioning in utero Prolonged or difficult labor

exacerbates dysfunction Risks

– Primiparous mother – LGA – Male – Breech – Multiples – Maternal uterine

abnormalities “Back to Sleep” effect

TorticollisTorticollisSBS & CN XI

Parallelogram Pattern Lateral Strain Deformity

Gastrointestinal System:Poor Feeding/Sucking

Goals & Considerations– Patients present with poor growth or irritability– Prolonged or difficult labor; eventual c-section

preventing initial gasp– Improve restrictions impinging on responsible

cranial nerves by decompressing surrounding sutures

Occipital Release Technique for Newborns and Infants

Support the patient’s body by cradling it with your forearm Support the head and palpate for motion with the ipsilateral

hand Support the sacrum and palpate for motion with 2 or 3 fingers

of the contralateral hand Grasp the cranium with fingers evenly splayed “as firmly as you

would a ripe tomato so as not to leave impressions” Feel subtle release of muscles and watch newborns face

content. Give newborn back to parent and observe improvement with

feeding.

Demonstrate the procedure on patient in front of director

Innervation TableInnervation TableOrgan/System Parasympathetic Sympathetic Ant.

Chapman'sPost.

Chapman's

EENT Cr Nerves (III, VII, IX, X)

T1-T4 T1-4, 2nd ICS

Suboccipital

Heart Vagus (CN X) T1-T4 T1-4 on L, T2-3

T3 sp process

Respiratory Vagus (CN X) T2-T7 3rd & 4th ICS T3-5 sp process

Esophagus Vagus (CN X) T2-T8 --- ---

Foregut Vagus (CN X) T5-T9 (Greater Splanchnic) --- ---

Stomach Vagus (CN X) T5-T9 (Greater Splanchnic) 5th-6th ICS on L

T6-7 on L

Liver Vagus (CN X) T5-T9 (Greater Splanchnic) Rib 5 on R T5-6

Gallbladder Vagus (CN X) T5-T9 (Greater Splanchnic) Rib 6 on R T6

Spleen Vagus (CN X) T5-T9 (Greater Splanchnic) Rib 7 on L T7

Pancreas Vagus (CN X) T5-T9 (Greater Splanchnic), T9-T12 (Lesser Splanchnic)

Rib 7 on R T7

Midgut Vagus (CN X) Thoracic Splanchnics (Lesser)

--- ---

Small Intestine Vagus (CN X) T9-T11 (Lesser Splanchnic) Ribs 9-11 T8-10

Appendix    T12 Tip of 12th Rib

T11-12 on R

Hindgut Pelvic Splanchnics (S2-4)

Lumbar (Least) Splanchnics --- ---

Ascending Colon  Vagus (CN X) T9-T11 (Lesser Splanchnic) R Femur @ hip

T10-11

Transverse Colon  Vagus (CN X) T9-T11 (Lesser Splanchnic) Near Knees ---

Descending Colon Pelvic Splanchnic (S2-4)

Least Splanchnic L Femur @ hip

T12-L2

Colon & Rectum Pelvic Splanchnics (S2-4)

T8-L2 --- ---

References:

Is their room for OMT therapy in your practice during the era of evidence-based medicine?– The Collected Papers of Viola M. Frymann, D.O.:

Legacy of Osteopathy to ChildrenIndividual copies are priced at $75 for the hardbound edition and $65 for the softbound edition. The

shipping and handling for mail orders is $7. Orders should be sent to: AAO, 3500 DePauw Boulevard, Suite 1080, Indianapolis, IN 46268-1136. Proceeds benefit the AAO and its programs.

– The Viscoplastic and Viscoelastic Axes of Motionin the Cranium/Documenting Cranial Dysfunction in Children

Print out the answer sheet to use with the following questions.

Circle the correct answer and review with director:

Question1: A, B, C, D, E. Question2: A, B, C, D, E. Question3: A, B, C, D, E.

1. Which nerve if in dysfunction will cause difficulties in swallowing and excessive gag reflex:A. CN VIIB. CN XI

C. CN XII D. CN IX

E. CN VI

2. Which nerve when in dysfunction will cause dysphagia, poor tongue function (latch-suckle):A. CN XIB. CN XIIC. CNV

D. CN VI E. CN VII

3. Which pattern of Cranial Plagiocephaly will present with a “flat head”:

A. Flexon

B. Extension

C. SBS strain

D. Torsion

E. Rotation

Certificate of Completion

I, _________________________, successfully completed the Pediatric OMT Module on __ __ 20__

Signatures: Pediatric Resident ____________________ Pediatric Residency Director____________

( Please print and give to program director.)

Congratulations