Knowledge of the neuromotor activity that underpins the baby’s breastfeeding actions, the theoretical manual therapy literature (Moeckel & Mitha, 2008; Sergueef, 2007)37, and anecdotal clinical evidence provides a clear rationale for the potential role of manual therapy to facilitate effective breastfeeding. However, only a small number of studies that explored this treatment approach were found, and many lacked critical supporting evidence. The findings from these studies, which involve manual therapies other than
35 See section 2.2.
36Cranio-sacral therapy is a derivative version of Osteopathy in the Cranial Field (OCF); a treatment approach based on the original teachings of Dr Sutherland, osteopath (Magoun, 1976). Cranio-sacral therapy has been adopted and taught extensively outside the osteopathic profession, and is frequently referred to in the breastfeeding literature.
37 For a more extensive list of the osteopathic theoretical literature see sections 2.7.1.1 Suck problems and 2.9.1.
27
osteopathy, are presented first, followed by those that use osteopathic treatment. Two of the more robust studies; clinical trials that investigated the use of chiropractic (Miller et al., 2009) and osteopathic (Fraval, 1998) treatment as interventions to promote effective breastfeeding, are presented in more detail.
Biedermann, an orthopaedic physician in Germany, conducted a number of observational clinically based studies, over a decade38. He reports typical developmental patterns that occurred in irritable but otherwise healthy babies and proposed a model to explain these observations called ‘kinematic imbalances due to suboccipital stress’ (KISS) (Biedermann, 2004a). Babies diagnosed with KISS were generally unsettled and had significant sleeping and feeding problems. It was postulated that dysfunction of the baby’s upper cervical spine and muscular tension, potentially as a consequence of prolonged and difficult labour, had a negative influence on behaviour and development. It was contended that manual therapy was able to successfully alleviate many of these symptoms; however, supporting evidence for these conclusions was not provided.
Two case studies involving chiropractic treatment of babies with breastfeeding difficulties were reported in one paper (Hewitt, 1999). The cases involved two infants, aged eight- weeks and four-weeks, who were diagnosed with mechanical lesions of the cranium and spine that were corrected by chiropractic adjustment and cranio-sacral therapy. In both cases, improved breastfeeding outcomes were reported. A clinical trial conducted by Vallone (2004) involved chiropractic assessment and treatment of 25 infants with breastfeeding difficulties. One of the study’s aims was to examine the variety of neuromotor causes for breastfeeding dysfunction. Each baby’s prenatal and birth history and physical findings were tabulated in detail. The conceptual basis to explain how biomechanical and neuromuscular problems could interfere with successful feeding was discussed and ‘craniocervical subluxation’39 was identified as one of the most important causative conditions. Treatment consisted of a variety of manual therapies, including cranio-sacral therapy, and an 80% post-treatment improvement in latch and ability to breastfeed was reported. Information to substantiate this outcome was, however, missing.
Miller et al. (2009) conducted a descriptive, clinical case series study of 114 infants, who were referred by a medical practitioner to a chiropractic clinic, with suboptimal breastfeeding. This diagnosis was made on the basis that the infant could not be fed exclusively at the breast. Infants underwent a biomechanical evaluation at the chiropractic
38 Biedermann’s work and that of other medical practitioners, who were members of the European Workgroup for Manual Medicine has been collated into a book (Biedermann, 2004b).
39 ‘Craniocervical subluxation’ is a clinical term specific to chiropractic. It refers to a degree of mal-alignment of the joints between the base of the skull and the upper cervical spine.
28
clinic and clinical findings were documented and later discussed. Infants then received routine care plus a course of chiropractic manual therapy treatment. Outcome measures involved the mother’s report on rating of improvement in breastfeeding (or not) on a 10- point numerical rating scale. After intervention, exclusive breastfeeding was reported for 89 infants (78%) within a 2-week time period. All mothers reported some improvement.
The authors concluded that cooperative multidisciplinary care was valuable in supporting women who want to exclusively breastfeed their babies, and that chiropractic treatment might be useful adjuvant therapy for breastfeeding problems with a biomechanical component. A recommendation was made for future randomised controlled study designs to more accurately determine the role of manual therapy in promoting breastfeeding.
2.9.1 Osteopathic treatment
Literature specific to osteopathy and breastfeeding difficulties is sparse, although breastfeeding difficulties are implicated in the wider spectrum of physical strains and unsettled behaviour of the newborn due to birth trauma. Several studies were undertaken in America, between the 1960’s to 1990’s by osteopaths, Frymann (1998) and Upledger (1996), which investigated the relationship between birth trauma, physical strains in the newborn and osteopathic assessment and treatment in the cranial field. Frymann’s clinical studies in paediatric osteopathy have been collated into a book (King, 1998). Taken within the context of the time, these early studies were exploratory and results were inconclusive, but suggestive of this being an important field for further study. Osteopathy in the Cranial Field (OCF)40, known also as cranio-sacral therapy, is a particular approach, which applies osteopathic principles in a detailed way to the head as part of the body. It has a special focus on babies and children due to the potential deleterious effects of the birth process on the immature cranium, spine, and developing systems. The theoretical literature and anecdotal evidence supports the value of OCF as a treatment approach suited to the paediatric population (Lay, 1997; Magoun, 1976; Moeckel & Mitha, 2008).
Studies that involved osteopathic treatment for babies with breastfeeding difficulties consist of three case studiesand one pilot clinical trial. The case studies share some common characteristics. They involve very young infants, aged twelve-hours (Rivera- Martinez, 2005), nine-days (Fraval, 1991), and eleven-days old (Palmer, 2005); a history of a difficult labour; and a baby who demonstrated a weak or dysfunctional suck that persisted after assistance from a lactation consultant. In all cases, OCF was the predominant treatment approach used by the osteopath and the initial findings of physical
40 See Chapter 10.3 for further information on osteopathic manual techniques, based on the principles of OCF.
29
strains resolved after one or two treatments and the baby was able to breastfeed effectively. The babies had been referred to the osteopath by a lactation consultant and the successful outcome was attributed to the combined management skills and techniques of practitioners from both disciplines.
Fraval (1998) undertook a pilot clinical trial to investigate the use of measuring and comparing differences in the pre- and post-feed breast milk fat concentration of breastfeeding infants as a means of determining their sucking efficiency. The study involved twelve healthy term breastfed infants: an experimental group of six, referred by a lactation consultant with a dysfunctional suck, and a control group of six, who were feeding without difficulty. The experimental group received osteopathic treatment, with an OCF approach, over one month. The initial small difference in this group’s individual pre- post-feed milk fat measures increased following a course of osteopathic treatment, to a level that was comparable with the ‘normal’ group. A significant relationship between osteopathic treatment and the changes in pre-post-feed milk fat concentrations was found.
The author contended that results could be attributed to an improved infant sucking ability, and recommended that the study be extended to a larger cohort. This pilot study investigates a simple, non-invasive empirical measure of an infant’s sucking ability;
however the validity of the measure as a research tool and the treatment effects of osteopathic treatment require further on-going scrutiny.
In summary, studies that investigate manual therapy as a strategy to assist with breastfeeding difficulties present a common rationale for this treatment approach based on an appreciation of the biomechanical elements of breastfeeding. In general, positive breastfeeding outcomes following manual therapy for the baby were found; however experimental evidence for the efficacy of manual therapy is limited and these conclusions require further investigation. Research has been unable to establish the effects of specific interventions, such as manual therapy, for breastfeeding difficulties, for several reasons.
This includes the lack of valid and reliable breastfeeding outcome measures, the complexity of other contributing factors such as psychosocial support, the involvement of other health practitioners, and the natural course of the condition. All studies did not address long-term follow up; an important issue considering concerns about the decline in duration of breastfeeding at six months.