The authors acknowledge Ost&#233;opathie Qu&#233;bec for a grant to publish this paper.

This randomized controlled trial protocol was approved by the Comit&#233; d&#8217;&#233;thique et de la recherche en sant&#233; de L&#8217;humain at the Centre hospitalier Universitaire de Sherbrooke and the Comit&#233; d&#8217;&#233;thique et de la recherche at the Centre int&#233;gr&#233; de sant&#233; et services sociaux de la Capitale Nationale in Qu&#233;bec City, Canada.
1. Identification of Collaborators and the Preparation of Recruitment
<ol>
	<li>Network with LCs and/or a local mother-to-mother support groups where frequent lactation consultations are provided in order to identify where the study will take place.</li>
	<li>Organize a training session (roughly 2 h) for potential recruiters (LCs from the group identified at step 1.1, external LCs, midwives, and perinatal nurses) on biomechanical suckling difficulties based on Genna&#8217;s description of the innate sequence of suckling behavior8, and the eligibility criteria for this study. Include a brief description of potential osteopathic techniques used in this context.</li>
	<li>Ensure that the LCs identified at step 1.1 are familiar with the tools used in the study and, if necessary, are trained to use the LATCH Assessment Tool, the VAS, and the questionnaires.
	<ol>
		<li>Test-run the protocol procedures, such as welcoming the mother-infant dyads, explaining and facilitating the signing of the consent form, and completing the assessment using the tools.</li>
	</ol>
	</li>
	<li>Validate the reliability of the osteopathic palpation with other osteopaths experienced in pediatric osteopathy. Train the study osteopath to be able to evaluate and perform the osteopathic treatment needed within 30 min maximum, in order to minimize inconsistencies arising from the infants&#8217; behavior, such as sleep stages and suckling skills and stamina.</li>
</ol>
2. Selection of Implementation Sites
<ol>
	<li>Select a site with at least two hospitable rooms with conveniences for families to host the study. Consider providing drinking water, a comfortable place to breastfeed, and diaper changing facilities. Also, provide pillows or cushions to support the mothers&#8217; arms, a footboard for better positioning, and chairs for family members accompanying the mother-infant dyad and the LC (when performing the evaluation). 
	NOTE: The rooms must be easy to access with a stroller and for mothers with limitations following a C-section delivery. A sofa is optimal, but a rocking chair for the mother plus a small bench for the osteopath is another option.</li>
</ol>
3. Recruitment and Enrollment of Mother-infant Dyads
<ol>
	<li>Identify eligible infants with biomechanical suckling dysfunctions through referrals from LCs, nurses in perinatal care, and midwives, after their first lactation consultation. Refer them to the study.
	<ol>
		<li>Select infants less than six weeks of age, with biomechanical suckling dysfunctions (suboptimal head extension, restricted head rotation, restricted mouth opening, jaw stiffness, habit of biting the nipple, restricted tongue mobility).</li>
		<li>Exclude infants with a cleft palate, cleft lip, surgical tongue-tie, or other medical conditions; twins; and infants with prior treatment using any type of manual therapy.</li>
	</ol>
	</li>
	<li>On the first appointment following the referral, welcome mother and infant and explain the full study process. Obtain informed consent.</li>
	<li>Once screened, clearly establish how parents will contact the clinic, to ensure a rapid turn-around for the intervention and to schedule an appointment. 
	NOTE: The LC provides an initial lactation consultation prior to the preintervention assessment and, then, determines the LATCH scores and the VAS pre- and postosteopathic intervention.</li>
</ol>
4. Assessment of Baseline Study Outcomes
<ol>
	<li>Ask the mother to give one breast. Observe the infant&#8217;s suckling rhythm.</li>
	<li>Assess the infant&#8217;s baseline ability to latch, using the LATCH Assessment Tool, right at the beginning of the feed. Be aware that, sometimes, infants are in a deep sleep and it may take a long time to awaken them. Be prepared to complete the administrative process quickly if the infant is hungry and upset prior to the feed.</li>
	<li>Request the mother to complete a VAS at the beginning of the feed.</li>
	<li>Administer a baseline questionnaire for sociodemographic data, breastfeeding data (e.g., number of feeds per day, number of bottle feeds versus breastfeeds, number of diapers changed in the last 24 h), and maternal perceptions of biomechanical difficulties (e.g., infant bites the nipple during the feed, opens his mouth widely to latch, or slips on the nipple while feeding).</li>
	<li>Ask the mother to remove the infant from the breast when the suckling movement is slowing. 
	NOTE: When the assessment is completed, the LC leaves the room.</li>
</ol>
5. Performance of an Osteopathic Assessment
<ol>
	<li>Open the sealed and opaque envelope with the corresponding study number for the mother-infant dyad, which will assign the dyad to the control or treatment group.</li>
	<li>Ask the mother to sit on a couch with a cushion on her knees and the infant lying back on it. Sit by her side. Connect with the infant by making eye contact. Talk to the infant before putting hands on its body.</li>
	<li>Begin with a general observation of the infant&#8217;s posture, tone, and any asymmetries.</li>
	<li>Assess the infant&#8217;s head passive rotation left and right with the goniometer. Respect any discomfort manifestation or limitation (for example, ipsilateral shoulder elevation).</li>
	<li>Observe the infant&#8217;s body attitude and assess any osteopathic lesions for each part of the body regardless of the allocation group, using the standardized grid described in Table 1.</li>
	<li>Begin the treatment with the pelvic area since it is an important sphere of compression during the birth process16,35. Assess the tissue texture and tone in the lower limbs&#8217; fascia, sacroiliac joints, sacrum, and hips, as well as the range of motion of the pelvic sphere versus the lumbar spine.</li>
	<li>Move hands from the infant&#8217;s pelvis to its skull and similarly assess tissue texture and tone and, as appropriate, the range of motion of the abdominal cavity, spine, diaphragm, thorax, and cervical spine. Pay careful attention to the first cervical vertebrae, and assess the anterior structures of the neck, the hyoid bone, and sublingual muscles.</li>
	<li>Be very precise and gentle as to the placement of fingers at the skull base, as structures are tiny and delicate.</li>
	<li>Move forward from the base of the skull to the occipital bone, temporal bones, parietal bones, sphenoid bone, frontal bone, and features of the face, including the jaw. Infants yawn frequently; observe the jaw movements and the symmetry of the face.</li>
	<li>For each structure, record observations of the texture, tone, quality and range of motion, and straining on the standardized grid (Table 1).</li>
</ol>
6. Performance of Osteopathic/Sham Intervention
NOTE: The osteopathic techniques described in this protocol are key osteopathic approaches available for infants with biomechanical suckling difficulties. They focus on improving the infant&#8217;s ability to latch, improving pelvic mobility, improving head rotation and extension, improving mouth opening, and freeing the XII cranial nerve, which is responsible for the tongue motion.
<ol>
	<li>Lie the infant down on his/her back on a pillow on his/her mother&#8217;s knees. Sit alongside the mother on the couch, at the infant&#8217;s head.</li>
	<li>Perform the osteopathic treatment.
	<ol>
		<li>Start the osteopathic treatment by addressing areas previously identified as dysfunctional.</li>
		<li>Begin by treating the pelvic area. Place the hands on each side of the infant&#8217;s pelvis, covering the iliac bones. Ensure that thumbs are on the anterior part of the iliac bones and fingertips are at the sacroiliac joint on each side. Using indirect technique, place the restricted structure in a comfortable position. Use continuous feedback until the complete loosening of the structure is achieved (known as a release)17,36.</li>
		<li>Place fingers of both hands around the occipital bone, tips of the ring fingers contacting the condyles area, index fingers contacting the mastoid area and middle fingers between the occipital bone and the first cervical vertebra, as described for the condylar decompression technique37. Gently separate the fingers in the various spatial plans until the tissues soften and the condyles move freely. 
		NOTE: At the upper cervical spine, spots are very close together and fragile.</li>
		<li>Place one hand under the occipital bone and the other on the frontal and sphenoidal bones, avoiding eyes, in a fronto-occipital hold17. Place the occiput and sphenoid in their position of least resistance. Monitor the decrease in resistance and readjust the positioning of the structures until the release occurs.</li>
		<li>Place one hand cupping under the occipital bone and the first three cervical vertebrae and the index finger and thumb of the other hand on each side of the hyoid bone. Wait until a release of the hyoid bone is felt through the structures in the other hand. Monitor and reassess, as done in a myofascial release technique36.</li>
		<li>End the osteopathic treatment by a global body harmonization. Put one hand on the pelvic area and the other on the skull. Gently balance the body volumes, addressing fascia, muscles, bones, and fluid, at least until a coherent and global release is perceived.</li>
	</ol>
	</li>
	<li>Perform a sham intervention.
	<ol>
		<li>Place hands on areas far from those with detected dysfunctions, without any intention of treatment.</li>
		<li>Answer questions from the parents about osteopathy and the infant&#8217;s psychomotor development.</li>
	</ol>
	</li>
	<li>Postpone the infant feed until the end of the intervention. Use a pacifier or the mother&#8217;s finger if necessary to soothe the infant.</li>
	<li>Assess the infant&#8217;s left and right passive head rotation with the goniometer.</li>
	<li>Make sure the evaluation and sham manipulation or the evaluation and osteopathic treatment have the same 30 min duration in order to keep the parents and the LCs blind as to treatment allocation.</li>
	<li>Leave the room. Fill in the standardized assessment grid (Table 1). Record details of the treatment performed.</li>
</ol>
7. Reassessment of the Mother-infant Dyad
NOTE: The LC re-enters the treatment room.
<ol>
	<li>Take time to set up the mother and the infant comfortably, to ensure the best conditions to take the breast again. Reassess the infant&#8217;s ability to latch with the LATCH Assessment Tool.</li>
	<li>Ask the mother to complete a second VAS.</li>
	<li>Perform a usual lactation consultation.</li>
	<li>Schedule a second appointment 48 h later. Inform the mother that there will be another breastfeeding evaluation, meaning that she will have to manage to feed her infant during this meeting.</li>
</ol>
8. Final Face-to-face Assessment
NOTE: For this assessment, parents will only meet an LC.
<ol>
	<li>Set up the mother and infant comfortably to create the best conditions to breastfeed. When the infant is ready (it may take some time), assess the ability to latch with the LATCH Assessment Tool.</li>
	<li>Ask the mother to complete a second VAS at the beginning of the feeding.</li>
	<li>Administer a second questionnaire for breastfeeding follow-up, maternal perceptions of the infant&#8217;s ability to latch, and perception of their allocated group.</li>
	<li>Perform a second lactation consultation.</li>
	<li>Offer osteopathic treatment for infants in the control group.</li>
	<li>Make a phone appointment one week following this second visit.</li>
</ol>
9. Assessment of the mother-infant dyad 10 days post enrolment
<ol>
	<li>Call the mother to complete the 10-day questionnaire, including breastfeeding follow-up and potential side effects. Remind the mother to complete the postal questionnaire, which includes a VAS and satisfaction component regarding their participation in the protocol.</li>
	<li>Wait to receive the postal questionnaire. Call back 1x if necessary.</li>
</ol>

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The authors have nothing to disclose.

This study is one of the first randomized controlled trials to assess the efficacy of an osteopathic treatment for infants with biomechanical suckling difficulties. When performed promptly, this intervention might reduce the risk of stopping breastfeeding earlier than originally intended.
With no prior models, this trial was designed pragmatically, including the need to act quickly to address breastfeeding difficulties and nipple pain that may be experienced with a newborn. The protocol also m...

An erratum was issued for: <a href="https://www.jove.com/video/58740/assessment-efficacy-an-osteopathic-treatment-infants-with">Assessment of the Efficacy of An Osteopathic Treatment in Infants with Biomechanical Impairments to Suckling</a>.&#160; An author name was&#160;updated.
One of the authors&#39; names was corrected from:
Juliette&#160;Herzaft-LeRoy
to:
Juliette Herzhaft-Le Roy

An erratum was issued for: <a href="https://www.jove.com/video/58740/assessment-efficacy-an-osteopathic-treatment-infants-with">Assessment of the Efficacy of An Osteopathic Treatment in Infants with Biomechanical Impairments to Suckling</a>.&#160; An author name was&#160;updated.

Erratum: Assessment of the Efficacy of An Osteopathic Treatment in Infants with Biomechanical Impairments to Suckling

Over the last thirty years, international recommendations from the World Health Organization1, followed by national recommendations in many countries2,3,4, have advocated for breastfeeding. Its health benefits are now well-known5,6 and breastfeeding exclusively for the first six months of the infant&#39;s life and maintaining it for two years or longer is described as the norm1.
As highlighted by Homdrum and Miller7, more than half of the mothers who stop breastfeeding within the first month reported biomechanical difficulties. Suckling biomechanical issues typically include suboptimal head extension and rotation, restricted mouth opening or jaw stiffness, biting the nipple, restricted tongue mobility, and inefficient mouth vacuum to stimulate the release of milk from the mother&#39;s breast8. Any neurological impairment also affects the optimal function of the normal primitive reflexes, crucial to an optimal latch.
The emergence of LCs worldwide has provided a great source of breastfeeding support for mother-infant dyads and has contributed to increasing the scientific knowledge in this specific field. For example, LCs have studied extensively the biomechanics of suckling from birth to weaning. In parallel, they have created tools to assess the function of breastfeeding and to efficiently detect dyads with special needs9,10.
Osteopathy is a manual practice meant to restore normal functions of the human body, based on the body&#39;s capacity for self-regulation11 and structure-function relationship1. During an osteopathic consultation, various palpation techniques are used, based on thorough knowledge of human anatomy and physiology12. Some scholars have linked physical restrictions with suckling dysfunction13,14,15,16,17. Restrictions of skull sutures or motility of skull bones have also been described to impact an infant&#39;s ability to latch13,14,15,16,17,18. However, research on the efficacy of osteopathy techniques on biomechanical suckling difficulties is scarce19,20.
Aside from a few case reports describing an osteopathic intervention to improve an infant&#39;s ability to latch21,22, only one pilot study23 documented the impact of such interventions. Six infants between three to six weeks of age were recruited and assessed by an LC. Mothers were given breastfeeding advice and then met the osteopath. Four treatments (once a week for four weeks) were performed. Treated infants were compared with six control infants whose mothers received only LC support. The authors found improvement in the milk fat content, which has been shown to be a marker for effective feeding24. Due to its small sample, these pilot study results are not generalizable but established the feasibility of a randomized controlled trial coupling the expertise of LCs and osteopaths.
These studies have paved the way for a single-blind randomized controlled trial to assess the efficacy of an osteopathic treatment coupled with lactation consultations on infants&#39; ability to latch. The protocol for this trial is presented herein. The trial took place in a mother-to-mother support group, where LCs provided lactation consultations three days a week, free of charge for parents25.
Assessment tools for the trial included 1) the LATCH Assessment Tool to measure the main aspects of the biomechanics of suckling26; 2) a VAS to assess the mother&#39;s nipple pain; 3) a goniometer, a soft plastic instrument to measure the rotation of the infant&#39;s head&#39;s angles; and 4) de novo questionnaires to assess the mother&#39;s perception of her infant&#39;s ability to latch, as well as sociodemographic data and potential intervention side-effects.
The LATCH Assessment Tool was chosen amongst several others for its specific assessment of the biomechanics of the suckling structures and the global ability of the mother-infant dyad to position themselves comfortably27. While breastfeeding assessment tools are currently discussed in the international lactation community28,29, the tool is easy to use in the clinic, reliable, and widely implemented among this community to detect early breastfeeding difficulties30. The choice of the tool also enables comparisons with other studies on breastfeeding. Each letter in &#34;LATCH&#34; corresponds to an item to assess an element of the biomechanics of suckling. &#34;L&#34; is for the ability of the infant&#39;s tongue, jaws, and lips to sustain the actions and vacuum, and to activate the milk let-down reflex efficiently (Latch). &#34;A&#34; is for Audible swallowing as it is evidence of suckling effectiveness, &#34;T&#34; is for the Type of the nipple at the end of the feed (inverted, flat, or everted), &#34;C&#34; is for the Comfort of the breast and nipple, and &#34;H&#34; is for the assessment of the ease with which the infant is Held in a comfortable and effective position at the breast. The result is a five-item score out of 10 (normal is 10 out of 10) with an interrater reliability of 0.9431,32.
The VAS is a 10 cm line to estimate the severity of pain felt by mothers, from 0 (no pain) to 10 (maximum pain). For this trial, the VAS was completed at the beginning of the feed, once the infant was latching on, and once the milk let-down had started.
A soft plastic goniometer was used to assess the passive rotation of the infant&#39;s head,&#160;as described by Cheng33. Assessments were completed immediately before and following the osteopathic assessment for the control group, and before the assessment and following the osteopathic treatment in the treatment group. Intrarater reliability has been reported to range from 0.83 to 0.98 for the head rotation assessment34.
Finally, a standardized assessment grid was completed by the osteopath for every infant involved in the study, documenting all of the areas exhibiting osteopathic lesions. Osteopathic lesions are areas with lack of mobility or motility, with excess rigidity, or with a lack of tone in the structure. Lesions are classified in three levels of severity, ranging from a structure with limited mobility to a stiff structure with no mobility. In the osteopathic treatment group, all structures addressed during the treatment were documented (Table 1).
Data were analyzed with an intention-to-treat analysis using descriptive statistics. Chi-square tests were used to explore potential correlations between all identified lesion sites and a one-point or more improvement on the LATCH Assessment Tool.

<table><tbody><tr><td>sofa or armchair</td><td></td><td></td><td>comfortable enough for a new mother with potential ceasarean section scar to stay half an hour with the infant in her arms and comfortable enough for the osteopath to perform the intervention</td></tr><tr><td>cushion</td><td></td><td></td><td>to put the infant on it and helpful if required,&amp;nbsp; to breastfeed the infant</td></tr><tr><td>Goniometer</td><td>Dufort et Lavigne or similar</td><td>ALM 324000</td><td>in smooth plastic, not too long to be handle with one hand</td></tr></tbody></table>

assessment of the efficacy of an osteopathic treatment in infants with biomechanical impairments to suckling

Breastfeeding can be challenging for mother-infant dyads experiencing biomechanical suckling difficulties. Although lactation consultants (LCs) all over the world have increased their skills in this field and can provide support to help position the infant at the breast, the impact of their intervention might be limited in the presence of stiff structures in the infants. Here we present a protocol for a randomized controlled trial to assess the efficacy of osteopathic treatment, coupled with lactation consultation, for infants&#39; biomechanical suckling difficulties. It proposes a set-up and a sequence of actions to ensure an optimal context for treatment, as well as a blinding of parents and LCs to the intervention. Data such as the infant&#39;s latch ability measured with the LATCH Assessment Tool, the mother&#39;s nipple pain with a visual analog scale (VAS), and the mother&#39;s perceptions are collected by LCs four times over a 10-day period. Osteopathic lesions are documented by the osteopath, using a standardized assessment grid. Structures of interest are coherent with the anatomical zones involved in latching onto the breast. This protocol also proposes a strategy to document systematically an osteopathic profile of infants with biomechanical suckling difficulties in their first weeks of life. The implementation of this protocol confirms its feasibility for osteopathic assessment and treatment and paves the way for future trials to further explore the efficacy of osteopathic techniques for infants with biomechanical suckling difficulties.

Ninety-seven mother-infant dyads were recruited and randomly assigned to one of the two study groups. The participants&#39; characteristics and delivery mode are summarized in Table 2. Only 1/3 had a natural birth, meaning that the other 2/3 experienced epidural and vacuum (15.9%), forceps-assisted (2.9%), or C-section (18.8%) births. In this study, all infants had skull lesions (Table 3). The posterior quarter represented by the occipital and the tempora...

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Assessment of the Efficacy of An Osteopathic Treatment in Infants with Biomechanical Impairments to Suckling

Osteopathy is an emerging field of clinical research. Here we present a protocol to assess the efficacy of an osteopathic intervention coupled with lactation consultation, in infants with biomechanical issues impeding breastfeeding.

Breastfeeding can be challenging for mother-infant dyads experiencing biomechanical suckling difficulties. Although lactation consultants (LCs) all over ...

assessment-efficacy-an-osteopathic-treatment-infants-with

Research

JoVE Journal

Medicine

8.9K Views.  Entraide Naturo-Lait. Het gebruik van osteopathische technieken voor het geven van biomechanische problemen wordt wijd verspreid in de praktijk, maar tot deze studie, is er geen empirisch bewijs dat het werkt. Borstvoeding moeilijkheden worden ondervonden door veel moeders tijdens de eerste weken van de postpartum periode. De gezamenlijke opzet van deze interventie is zeer pragmatisch voor deze ouders.Op de eerste afspraak na de verwijzing, welkom de moeder en baby en leg het volledige studieproces. Na het ...

Video: Assessment of the Efficacy of An Osteopathic Treatment in Infants with Biomechanical Impairments to Suckling

Assessment and Evaluation of the High Risk Neonate: The NICU Network Neurobehavioral Scale

There has been a long-standing interest in the assessment of the neurobehavioral integrity of the newborn infant. The NICU Network Neurobehavioral Scale (NNNS) was developed as an assessment for the at-risk infant. These are infants who are at increased risk for poor developmental outcome because of insults during prenatal development, such as substance exposure or prematurity or factors such as poverty, poor nutrition or lack of prenatal care that can have adverse effects on the intrauterine environment and affect the developing fetus. The NNNS assesses the full range of infant neurobehavioral performance including neurological integrity, behavioral functioning, and signs of stress/abstinence. The NNNS is a noninvasive neonatal assessment tool with demonstrated validity as a predictor, not only of medical outcomes such as cerebral palsy diagnosis, neurological abnormalities, and diseases with risks to the brain, but also of developmental outcomes such as mental and motor functioning, behavior problems, school readiness, and IQ. The NNNS can identify infants at high risk for abnormal developmental outcome and is an important clinical tool that enables medical researchers and health practitioners to identify these infants and develop intervention programs to optimize the development of these infants as early as possible. The video shows the NNNS procedures, shows examples of normal and abnormal performance and the various clinical populations in which the exam can be used.

The NICU Network Neurobehavioral Scale (NNNS) was developed as an assessment for the at-risk infant. The purpose of this article is to describe the NNNS, provide video examples of the NNNS procedures and discuss the ways in which the exam has been used.

There has been a long-standing interest in the assessment of the neurobehavioral integrity of the newborn infant.  The NICU Network Neurobehavioral Scale ...

Behavior

Quantitative Assessment of Cortical Auditory-tactile Processing in Children with Disabilities

Objective and easy measurement of sensory processing is extremely difficult in nonverbal or vulnerable pediatric patients. We developed a new methodology to quantitatively assess children&#39;s cortical processing of light touch, speech sounds and the multisensory processing of the 2 stimuli, without requiring active subject participation or causing children discomfort. To accomplish this we developed a dual channel, time and strength calibrated air puff stimulator that allows both tactile stimulation and sham control. We combined this with the use of event-related potential methodology to allow for high temporal resolution of signals from the primary and secondary somatosensory cortices as well as higher order processing. This methodology also allowed us to measure a multisensory response to auditory-tactile stimulation.

Objective and easy measurement of sensory processing is extremely difficult in nonverbal or vulnerable pediatric patients. We developed a new methodology to quantitatively assess infants and children&#39;s cortical processing of light touch, speech sounds, and the multisensory processing of the 2 stimuli, without requiring active subject participation or causing discomfort in vulnerable patients.

Objective and easy measurement of sensory processing is extremely difficult in nonverbal or vulnerable pediatric patients. We developed a new methodology ...

Electrophysiological Measurements and Analysis of Nociception in Human Infants

Pain is an unpleasant sensory and emotional experience. Since infants cannot verbally report their experiences, current methods of pain assessment are based on behavioural and physiological body reactions, such as crying, body movements or changes in facial expression. While these measures demonstrate that infants mount a response following noxious stimulation, they are limited: they are based on activation of subcortical somatic and autonomic motor pathways that may not be reliably linked to central sensory processing in the brain. Knowledge of how the central nervous system responds to noxious events could provide an insight to how nociceptive information and pain is processed in newborns.
The heel lancing procedure used to extract blood from hospitalised infants offers a unique opportunity to study pain in infancy. In this video we describe how electroencephalography (EEG) and electromyography (EMG) time-locked to this procedure can be used to investigate nociceptive activity in the brain and spinal cord.
This integrative approach to the measurement of infant pain has the potential to pave the way for an effective and sensitive clinical measurement tool.

The assessment and treatment of pain in infants is difficult because infants cannot verbally report their experience. In this video we describe quantitative electrophysiological methods and analysis techniques that can be used to measure the response to noxious events from the infant nervous system.

Pain is an unpleasant sensory and emotional experience. Since infants cannot verbally report their experiences, current methods of pain assessment are ...

Neuroscience

Osteopathic Manipulative Treatment as a Useful Adjunctive Tool for Pneumonia

Pneumonia, the inflammatory state of lung tissue primarily due to microbial infection, claimed 52,306 lives in the United States in 20071 and resulted in the hospitalization of 1.1 million patients2. With an average length of in-patient hospital stay of five days2, pneumonia and influenza comprise significant financial burden costing the United States $40.2 billion in 20053. Under the current Infectious Disease Society of America/American Thoracic Society guidelines, standard-of-care recommendations include the rapid administration of an appropriate antibiotic regiment, fluid replacement, and ventilation (if necessary). Non-standard therapies include the use of corticosteroids and statins; however, these therapies lack conclusive supporting evidence4. (Figure 1)

Osteopathic Manipulative Treatment (OMT) is a cost-effective adjunctive treatment of pneumonia that has been shown to reduce patients&#8217; length of hospital stay, duration of intravenous antibiotics, and incidence of respiratory failure or death when compared to subjects who received conventional care alone5. The use of manual manipulation techniques for pneumonia was first recorded as early as the Spanish influenza pandemic of 1918, when patients treated with standard medical care had an estimated mortality rate of 33%, compared to a 10% mortality rate in patients treated by osteopathic physicians6. When applied to the management of pneumonia, manual manipulation techniques bolster lymphatic flow, respiratory function, and immunological defense by targeting anatomical structures involved in the these systems7,8, 9, 10.

The objective of this review video-article is three-fold: a) summarize the findings of randomized controlled studies on the efficacy of OMT in adult patients with diagnosed pneumonia, b) demonstrate established protocols utilized by osteopathic physicians treating pneumonia, c) elucidate the physiological mechanisms behind manual manipulation of the respiratory and lymphatic systems. Specifically, we will discuss and demonstrate four routine techniques that address autonomics, lymph drainage, and rib cage mobility: 1) Rib Raising, 2) Thoracic Pump, 3) Doming of the Thoracic Diaphragm, and 4) Muscle Energy for Rib 1.5,11

Pneumonia is one of the top ten leading causes of death in the U.S. Osteopathic manipulative techniques (OMT) may be utilized as an adjunctive therapy in the treatment of pneumonia to enhance biomechanical and immune function; and ultimately, to reduce hospital stay, duration of antibiotics, incidence of respiratory failure, and mortality. In this video-article, we will review randomized controlled studies on the use of OMT in pneumonia patients, as well as demonstrate specific hands-on techniques that are routinely practiced by osteopathic physicians when treating pulmonary infections.

Pneumonia, the inflammatory state of lung tissue primarily due to microbial infection, claimed 52,306 lives in the United States in 20071 and resulted in ...

A Common Marmoset Model of Mother-Infant Intervention for Breastfeeding Disorders in the Presence of Paternal Inhibition and Maternal Neglect

Parents&#39; psychological stress during the perinatal and neonatal periods continues to increase in an environment of declining birthrates, aging populations, and shrinking family sizes. The increase in child abuse and neglect cases, most likely by inexperienced and insufficiently knowledgeable parents, necessitates education on childcare and intervention techniques in nursing and midwifery training. In particular, attachment formation early in life between mother and infant is crucial. To accurately teach sensitive and comprehensive information on intervention techniques for mother-child attachment formation, realistic videos, and educational materials are necessary. Although pseudoeducational materials are available, they might be limited in explaining complex realism, particularly to support breastfeeding that involves both parents and child and that encourages interaction between the two.
In a previous study in a common marmoset (Callithrix jacchus) model, we experimentally controlled infant feeding and nurturing through 24 h of constant sensing and collected 1 month of quantitative data on psychological indices that possibly translated to psychological development. Age-dependent dynamic visualization of these data by multivariate analyses inferred causal relationships between early parental feeding and psychobiological rhythm formation. In the same primate model, we identified a spontaneous case of breastfeeding failure in which the father inhibited his neonatal infant&#39;s feeding and the mother appeared to abandon nurturing, leading to clinically significant weight loss in the infant.
Thus, we explored intervention techniques to promote mother-infant interaction. The mother was trained to allow the infant to spontaneously explore her breast. Initially, the mother refused to display the feeding pose potentially due to pain associated with breast engorgement. Massage was used to soften the breast and feeding was reintroduced. We hypothesize that activation of instinctive attachment formation mechanisms by encouraging spontaneity in each parent and child is the key to successful feeding intervention.

Here, we present a nonhuman primate model of mother-infant intervention for breastfeeding disorders in the presence of paternal inhibition and maternal neglect. The mate model video complements education to support primate and human caregivers with respect to infants with breastfeeding problems such as pain.

Parents&#39; psychological stress during the perinatal and neonatal periods continues to increase in an environment of declining birthrates, aging ...

Adapting Human Videofluoroscopic Swallow Study Methods to Detect and Characterize Dysphagia in Murine Disease Models

This study adapted human videofluoroscopic swallowing study (VFSS) methods for use with murine disease models for the purpose of facilitating translational dysphagia research. Successful outcomes are dependent upon three critical components: test chambers that permit self-feeding while standing unrestrained in a confined space, recipes that mask the aversive taste/odor of commercially-available oral contrast agents, and a step-by-step test protocol that permits quantification of swallow physiology. Elimination of one or more of these components will have a detrimental impact on the study results. Moreover, the energy level capability of the fluoroscopy system will determine which swallow parameters can be investigated. Most research centers have high energy fluoroscopes designed for use with people and larger animals, which results in exceptionally poor image quality when testing mice and other small rodents. Despite this limitation, we have identified seven VFSS parameters that are consistently quantifiable in mice when using a high energy fluoroscope in combination with the new murine VFSS protocol. We recently obtained a low energy fluoroscopy system with exceptionally high imaging resolution and magnification capabilities that was designed for use with mice and other small rodents. Preliminary work using this new system, in combination with the new murine VFSS protocol, has identified 13 swallow parameters that are consistently quantifiable in mice, which is nearly double the number obtained using conventional (i.e., high energy) fluoroscopes. Identification of additional swallow parameters is expected as we optimize the capabilities of this new system. Results thus far demonstrate the utility of using a low energy fluoroscopy system to detect and quantify subtle changes in swallow physiology that may otherwise be overlooked when using high energy fluoroscopes to investigate murine disease models.

This study successfully adapted human videofluoroscopic swallowing study (VFSS) methods for use with murine disease models for the purpose of facilitating translational dysphagia research.

This study adapted human videofluoroscopic swallowing study (VFSS) methods for use with murine disease models for the purpose of facilitating ...

Methods for In Vivo Biomechanical Testing on Brachial Plexus in Neonatal Piglets

Neonatal brachial plexus palsy (NBPP) is a stretch injury that occurs during the birthing process in nerve complexes located in the neck and shoulder regions, collectively referred to as the brachial plexus (BP). Despite recent advances in obstetrical care, the problem of NBPP continues to be a global health burden with an incidence of 1.5 cases per 1,000 live births. More severe types of this injury can cause permanent paralysis of the arm from the shoulder down. Prevention and treatment of NBPP warrants an understanding of the biomechanical and physiological responses of newborn BP nerves when subjected to stretch. Current knowledge of the newborn BP is extrapolated from adult animal or cadaveric BP tissue instead of in vivo neonatal BP tissue. This study describes an in vivo mechanical testing device and procedure to conduct in vivo biomechanical testing in neonatal piglets. The device consists of a clamp, actuator, load cell, and camera system that apply and monitor in vivo strains and loads until failure. The camera system also allows monitoring of the failure location during rupture. Overall, the presented method allows for a detailed biomechanical characterization of neonatal BP when subjected to stretch.

Methods for In Vivo Biomechanical Testing on Brachial Plexus in Neonatal Piglets

Presented here are methods to perform in vivo biomechanical testing on brachial plexus in a neonatal piglet model.

Neonatal brachial plexus palsy (NBPP) is a stretch injury that occurs during the birthing process in nerve complexes located in the neck and shoulder ...

Bioengineering

Ultrasound-guided Botulinum Toxin-A Injections: A Method of Treating Sialorrhea

Neurological diseases can be complicated by sialorrhea, an excessive flow of saliva. Patients suffering from moderate to severe sialorrhea have an impaired quality of life, often worsened by correlated complications such as aspiration pneumonia, oral infections, dental caries, and maceration of the skin. Diverse therapeutic approaches have been proposed for the treatment of sialorrhea, including surgery and the use of anticholinergic agents, with limited results and the possible occurrence of serious adverse events. Recently, botulinum toxin (BoNT) injection within the major salivary glands has been proposed in patients refractory to anticholinergic therapy, with the aim of inhibiting local acetylcholine release and gland activity. 
In order to obtain a better outcome in terms of reduction of saliva production, efficacy, duration, and avoidance of major adverse events, we developed an ultrasound-guided BoNT-type A injection technique accurately described in the text. Here we present a method of treating sialorrhea with bilateral parotid and submandibular gland BoNT-type A injections under ultrasound guidance. Four quadrants of the parotid gland and two quadrants of the submandibular gland are visualized and injected using two accesses and one access, respectively. 
The ultrasound-guided procedure provides a simple, non-invasive, real-time visualization of the muscular and glandular tissues and their surrounding structures, optimizing treatment efficacy and safety.

Botulinum toxin is injected into the salivary glands for the treatment of sialorrhea. The ultrasound-guided botulinum toxin injection in both the parotid and submandibular glands demonstrates a sustained efficacy and the absence of serious side effects.

Neurological diseases can be complicated by sialorrhea, an excessive flow of saliva. Patients suffering from moderate to severe sialorrhea have an ...

A Custom-Made Pressure Transducer System to Record Non-Nutritive Suck Bursts

Non-Nutritive Suck Parameters Measurements Using a Custom Pressure Transducer System

The non-nutritive suck (NNS) device is a transportable, user-friendly pressure transducer system that quantifies infants' NNS behavior on a pacifier. Recording and analysis of the NNS signal using our system can provide measures of an infant's NNS burst duration (s), amplitude (cmH2O), and frequency (Hz). Accurate, reliable, and quantitative assessment of NNS has immense value in serving as a biomarker for future feeding, speech-language, cognitive, and motor development. The NNS device has been used in numerous research lines, some of which have included measuring NNS features to investigate the effects of feeding-related interventions, characterizing NNS development across populations, and correlating sucking behaviors with subsequent neurodevelopment. The device has also been used in environmental health research to examine how exposures in utero can influence infant NNS development. Thus, the overarching goal in research and clinical utilization of the NNS device is to correlate NNS parameters with neurodevelopmental outcomes to identify children at risk for developmental delays and provide rapid early intervention.

Author Spotlight: Implications of Non-Nutritive Sucking on Speech Emergence and Infant Development

The non-nutritive suck (NNS) device can easily collect and quantify NNS features using a pacifier connected to a pressure transducer and recorded through a data acquisition system and laptop. Quantification of NNS parameters can provide valuable insight into a child's current and future neurodevelopment.

The non-nutritive suck (NNS) device is a transportable, user-friendly pressure transducer system that quantifies infants' NNS behavior on a pacifier. ...

Investigating Orthodontic Tooth Movement and Bone Adaptation Mechanisms in Mice

Studying Orthodontic Tooth Movement in Mice

Orthodontic tooth movement (OTM) represents a dynamic process in which the alveolar bone undergoes resorption at compression sites and deposition at tension sites, orchestrated by osteoclasts and osteoblasts, respectively. This mechanism serves as a valuable model for studying various aspects of bone adaptation, including root resorption and the cellular response to mechanical force stimuli. The protocol outlined here offers a straightforward approach to investigate OTM, establishing 0.35 N as the optimal force in a mouse model employing a nickel-titanium (NiTi) coil spring. Utilizing micro-computed tomography analysis, we quantified OTM by assessing the discrepancy in the linear distance at the cement-enamel junction. The evaluation also included an analysis of orthodontic-induced inflammatory root resorption, assessing parameters such as root mineral density and the percentage of root volume per total volume. This comprehensive protocol contributes to advancing our understanding of bone remodeling processes and enhancing the ability to develop effective orthodontic treatment strategies.

Here, we present a protocol for studying orthodontic tooth movement (OTM), serving as a suitable model for investigating the mechanisms of bone adaptation, root resorption, and the response of bone cells to mechanical stimuli. This comprehensive guide provides detailed information on the OTM model, micro-computed tomography acquisition, and subsequent analysis.

Orthodontic tooth movement (OTM) represents a dynamic process in which the alveolar bone undergoes resorption at compression sites and deposition at ...

Assessment of the Efficacy of An Osteopathic Treatment in Infants with Biomechanical Impairments to Suckling

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