A Pilot Study: Osteopathic Treatment of Infants with a Sucking Dysfunction

-13 m m I m

A pilot study: m Osteopathic treatment of infants m with a sucking dysfunction by Maxwell M.P.R. Fraval DO, M. Osteo. Sc. (Paed.) 0

Editor's Note: Dr. Manvell is an affiliate member Acknowledgments of the American Academ y of Osteopath y as well as This research ninth not have been possible without The Cranial Academ y. He currently is in practice in the support of a grant from the Frank and Janet Australia. Williams Charitable Trust through the kind assistance of Mrs. Man Terracall. Abstract The estimation of the fat content of breastmilk, by I particularly wish to acknowledge the early simple centrifuge method, is a reliable measure that encouragement received from Dr John Harakal is easily obtained. Estimations from six infants who (now deceased), Orme) . President of the Sutherland were feeding normally demonstrate that it provides Cranial Teaching Foundation and Professor of a gold standard against which patient outcomes can Osteopathic Manipulative Medicine at the Texas be measured. College of Osteopathic Medicine. A pilot study of six infants is reported on. At the time of first measurement. the difference Thanks are also due to Di: Viola Ervinatm, Director between pre- post feed fat estimations of breastmilk of the Osteopathic Childrens Centre in San Diego was small in infants with a dysfunctional suck. California and Dr. Edna Lay, Vice President of the Following osteopathic treatment the difference Sutherland Cranial Teaching Foundation. between pre- post feed fat estimations were comparable with the fat estimations from the I am also much indebted to Professor Peter breastmilk of infants who were feeding normally. Hartmann of the Department of Biochemistr y at the The results are encouraging enough to warrant University of Western Australia who so freely extending this to an age- and sex-matched case- provided me with information about his research. control study. The estimation of fat concentration in breastmilk was one of the measurement techniques to whirl he Key words drew m y attention. Breastmilk fat estimation, sucking dysfunction, lactation and osteopathic treatment.

* 51 Learmonth Drive. Kambah 2902 A.C.T. Australia: Telephone +61 2 6231 911 1; Facsimile +61 2 6231 9195: E-mail [email protected] Supported by a grant from the Frank and Janet Williams Charitable Trust through the kind assistance of Mrs. Mary Terracall. Introduction or up to hourly), an increase in milk secretion occurred only Osteopaths has been reported as effectively delivering in the gland that had been milked more frequently:" paediatric care. 1 -1-3A-5.7." This study assumed that. as pro- It is accepted that fat content of human milk is greater posed by Sutherland." there is a pattern of normal motion in the hind milk than in the fore milk:T=13 An infant that in the cranium that is present throughout life and that the is feeding effectively will take both fore milk and hind hirth process may produce strain patterns within the cra- milk at each feed. One way of measuring the extent to nium which may alter normal physiology. The scientific which the breast is emptied is M measuring the fat con- basis for this was recently reviewed by Myers." The study tent before and after each feed. The assumption that an further assumed that these strain patterns can be recognised infant with a dysfunctional suck, will on lc effect a small and accurately recorded by, careful palpation:: variation in the pre- and post-feed breastmilk fat estima- At parturition the tentorium cerebelli and falx cerebri tions was tested in this pilot study. The greater the differ- can sustain tremendous strain" with consequent defor- ence between pre-post fat concentrations, the more the mation: 4i Initiall y . the head presents in the transverse infant would demonstrate the ability to effectively empty diameter of the pelvic brim with the occiput to the left the breast of milk and attain the fat-rich hind milk. side of the maternal pelvis. Rotational forces affect the The aims of this pilot study were to establish the feasi- occiput which engages eccentrically with one part lead- bility of utilising the estimation of the concentration of ing first ( asynclitism 1. I breastmilk fat as a standard for measuring performance Particularly in the case of a prolonged second stage or outcomes in infants with a dysfunctional suck. The pre- other complication, the resulting micro- or macro-trauma post feed fat concentrations in the breastmilk of six moth- has been postulated ( within the osteopathic profession) to ers whose infants were feeding normally was measured. cause distortion of function in both the bony and soft tis- The results are described and analysed to assess whether sues as well as related fluid (vascular, lymphatic and cere- a standard had been established against which the progress brospinal) systems.":":":" of infants with sticking problems could he compared. Magoun states that a commonly occurring distortion re- Further, six infants who were feeding normally were sulting from the birth process is an approximation of the assessed to establish the difference between pre- post feed anterior ends of the condylar parts which "may have the ef- fat concentrations. A pilot study of six treated babies (each fect of putting increased tension through the slip of dura mater of which was treated for 4 weeks) then assessed whether, that divides the jugular foramen and thereby irritating the when first measured, the difference between pre- post feed cranial nerves (Glossopharyngeal. Vagus and Accessory fat concentrations was less than normal babies. It was then nerves) passing through the area. In addition the petrosal considered whether osteopathic treatment of these infants and sigmoid sinuses are vulnerable to distorted function as improved their pre- post feed fat concentrations to a level they exit through the jugular foramina carrying 95 percent that compared favorably with normal infants. of the drainage from the head. Circulatory retardation may result in ischaemia- (Magoun 1975: p2501. The literature The irritation of the vagus nerve as it passes through The current interest in autocrine control of lactation, the jugular foramen or of the hypoglossal nerve as it passes and the interest in the fat component of milk, has high- through the hypoglossal canal" may affect the infants lighted the possibility of fat concentration as a marker for ability to suck or swallow. Infants have been treated to effective feeding. It has been noted that the fat concentra- resolve cranial strains in the United States of America since tion in breastmilk varies over 24 hours. 21 " When milk the 1940s where the clinical effectiveness of osteopathic that was stored in a goats gland was not milked, but di- treatment has been observed." luted with an inert solution, the secretory rate in- Considerable interest in the fat content of milk has been creased.26.27.28 This suggests that it is not the mere empty- seen in recent years. It has been postulated" that milk se- ing of the gland. but the concentration/dilution of sub- cretion is modulated by local chemical feedback inhibi- stances within it, that determine milk production. This view tion, and that there is some mechanism operating. within was strengthened by the observation that the goats gland the breast tissue, that is additional to hormonal control that had been milked three or more times daily had a greater ( via prolactin. growth hormone and oxytocin). The inhibi- number of secretory cells than the gland that had only tor is thought to be present in the milk itself and to have a been milked twice daily:".":" More recently it has been regulatory effect. shown that it is the extent to which the breast is emptied. In one study it was shown that if only one of the glands of rather than the frequency of feeding, that is important in goats were milked more than twice daily (three times daily the short-term control of the human milk supply." Milk synthesis in the alveoli of the mammary glands is a com- Strain means sufficient force to cause deformation of tissue. 26/AAO Journal Summer 1998 plex process involving at least four secretory mechanisms. may cause their mothers to experience nipple pain." It is These include exocytosis, fat synthesis and transfer, se- important, where such pain persists, to exclude the possi- cretion of ions and water and immunoglobulin transfer bility of Candida albicans as a cause,' rather than assume from the extracellular space.'' The average lipid content that the pain is caused by the infant's sucking. However, of human milk ranges from 3.2 - 3.5g/100m1" whereas having excluded this possibility, it is certainly recognised colostrum, which is the initial fluid released during the that pain can result from an infant's dysfunctional suck first few days of lactation, contains about 2.9g fat/100ml." (which invariably leads to exquisitely tender, cracked and/ The fat in human milk occurs as microscopic globules 2-, or bleeding nipples of the breast-feeding mother) and that 3 pm in diameter and coated with a membrane derived from this alters the milk composition or secretion." This ma- the mammary epithelial cell that secreted it. Fat, which con- ternal nipple pain resulting from an infant's dysfunctional stitutes 50 percent of the total energy value of human milk, sucking can be severe." The maternal record of pain on a plays an essential role in infant nutrition since it is vital to visual analog scale can be a useful indicator of improve- normal brain development, the structure and function of cell ment in the infant's sucking. membranes and for prostaglandin synthesis.' Woodward has noted that a far more dramatic increase Method in fat content occurs if an infant feeds from only one breast A simple technique for estimating fat concentration has at any one feed. The concentration in the hind milk is typi- been described" .'0 and has been the basis for estimations cally at least twice that in the fore milk." As the volume in this study. The estimation was made by the centrifuga- of milk in the breast decreases, higher levels of fat, so- tion of milk in a Sarvall Capspin haematocrit centrifuge dium and immunoglobulins. and lower levels of lactose for a period of 15 minutes. are found." The endocrine control of lactation involves The samples (of approximately 0. 1ml) were centrifuged control prolactin and growth hormone-1" which governs at 12.000rpm using micro-haematocrit tubes that were milk. production and oxytocin which governs milk ejec- 75mm in length and an inner diameter of 1.1 - I .2mm. tion. So for example, growth hormone has been shown to The tubes were sealed with Seal-ease (Clay Adams ) and increase the breastmilk in the mothers of pre-term infants." after centrifugation, the length of the cream column for Insofar as milk ejection. it is now thought that the event each tube was measured. This gave a so called creamatocrit described as "the milk coming in" which occurs 24-48 reading. hours after birth marks the shift from lactation driven by In view of Woodward D.R. Boon J. and Rees B.'s endocrine to lactation under autocrine control."'' study'" the mothers of infants being measured were ad- Serum prolactin concentration levels increase substan- vised to feed from one breast only. Creamatocrit readings tially during pregnancy from the nonpregnant level of were made from breastmilk taken from the same breast. about 10 nanograms/ml (Ipm = 1000 nanograms ). How- The samples were taken by expressing a few millilitres of ever its concentration decreases sharply after pregnancy breastmilk before and after each feed. All fat estimations and at 4 weeks postpartum it is about 20-30 nanograms/ were made between 5:00 pm - 7:00 pm as this appears to ml." This reduction in the prolactin production occurs at be the time of day when the fat concentration in breastmilk a time when milk production has been established and is high. This ensured the widest possible difference be- there is a need for it to continue for many months. It sug- tween pre- and post-feed fat concentration. gests that another mechanism for regulation is in the as- cendant and is associated with longitudinal changes in The inclusion criteria for this study are set out below. human milk yield and composition.' I. Be of an appropriate weight for gestational age: and A study of mothers who were breast-feeding infants 2. Had an Apgar score of 7 or more after 5 minutes older than I month," found that whilst the concentration after birth: and of prolactin in the mothers related to the degree of full- 3. Be less than 6 months of age; and ness in the breast, there was no relationship between the 4. Be attempting to breast-feed and are reported as hav- concentration of prolactin in the plasma and the rate of ing. a weak or dysfunctional suck: and synthesis. So that whilst prolactin is important in the ini- 5. Be seen by a lactation consultant for at least two tial phase of lactation, autocrine regulation becomes more weeks prior to the inclusion in the study; and important thereafter. 6. Be seen 21 days or more postnatally; and Apart from the question of autocrine control it is im- 7. Consented through their parents prior to the palpa- portant to refer briefly to a separate issue. This concerns tory assessments, sucking measurements and/ or the level of maternal pain associated with breast-feeding breastmilk fat estimations. an infant with a sucking dysfunction. It is recognised that in the early stages of breast-feeding, even normal infants Summer 1998 AAO Journal/27 The exclusion criteria for the study were: I . Infants less treatment commenced and some had been seen since birth. than 21 days old; (Note: the sucking measurements and In all cases the mothers had received advice about pos- breastmilk fat estimations form the base-line for infants ture. the method of attachment and the positioning of the with dy %junction to he measured in a later study. If infant infant. Where it was considered appropriate by the lacta- under 21 days were not excluded, improvements in this tion consultant, the mother was taught manual oral/lin- latter group might otherwise be attributable to maturation gual exercises to normalise the infants tongue movements. only. An extension of this study. if carried out subsequently, Each mother and infant had been supervised by a lacta- will have to ensure that treated and control groups are tion consultant during at least one feed and most had been matched for age and sex.) 2. Infants with a diagnosed dys- accompanied in this way several times. Infants were only phagia of which the sucking disorder forms a part. referred for inclusion in the study when the lactation consultant was satisfied that no further advice could he of- All six of the treated infants had been seen by a lacta- fered regarding posture or technique. The greatest differ- tion consultant for at least two weeks before osteopathic ence between pre- and post feed was seen in treated baby continued on page 30 Results Six samples of normal infants were taken in a pilot study. The results are set out in Table 1 below.

Fat Estimation DOB. Test date Feed @ Pre-feed Post-feed

Baby A.P 6.10.96 18.1.97 5-30- 6.00 p.m. 4nim I -hrim Baby R.E. 21.10.96 19.1.97 6.00 - 6.20 p.m. 3min 10mm Baby A.D. 26.6.96 21.1.97 5.45 - 5.55 p.m. 4111111 I2m m Baby L.M. 10.12.96 24.1.97 6.50 - 7.00 p.m. 2mm I 1 nun Baby N.S. I 2.9.96 28.1.97 6.00 - 6.15 p.m. 2mm 8111111 Baby J.F. 21.12.96 29.1.97 6.50 - 7.10 p.m. 2mm 9mm

Table I. Pre- and postfeed breastmilk fat estimations of 6 normal infants.

In the normal group. the average fat estimation at the onset of The average difference between pre-post feed fat esti- a feed was 2.83 mm, and at completion was 10.67 mm. The mation was 7.84 mm. variance associated with results for normal babies was:- A small number of babies with a dysfunctional suck Pre-feed average 2.83 Standard deviation 0.98 were treated and the results of each are included in Tables Post-teed average 10.67 Standard deviation 2.16 2-7.

i I I I -- 22 22 20 - 20 — - - --I -- - — --- IS —_ i, I f — — -- • • 2 65. • - le le 0 664/ BABY in ,. 1-_ t• Peet4Pne1eed Gat-tee tend Ddletence De Vend 12 - 12 UMW) I 2344•• 5 9 i 99 ]0 •.2 la 1.0 2 304Aer 3 11 5 109 95 6.9 -....."------;-°----#.°°.°.; 3 6414 • 5 1• 122 95 92 • • a • 13.4e• 25 la ISO 115 122 Olean 3.75 • • Sid Env 1 19 red • • r• 09406 • • • e • -.--.-...... -- . . 21 -•••• 20-•••• 21 -1•16. "46 10- 1e-en o • 3 - I I —1— Linn, regneelon analysts `lase swans waffled) her Pre- and Poet-Feed CIffereneee • Olnereece nitre/on lot the Am y • eta • • 3 a• dfrz taroye .5 2 65 067931 sencied erne value fee b 1.162393 3 r7 - aeedfssent el O• as. 01194724 The sandmen lee Oa a 1. 512+•9 ---1155 5 r- F ssadeinp.obearal ,•••••) 15 34973 d1 - do 2 wog - nhenseon sunof quern 35 I 125 as • roodu• e.g., et weans • 575

Table 2. Analysis of treated baby #1 28/AAO Journal Summer 1998 _ L _ I _ __ _ I 22 22 o Ei r° _. 1 y.5 05x 2 75 a _ . R 4 0 972 la _ ,s BABY X2 4 _ _ 14 ost-1 bend Ddlerence DM bend " (linear near) 1 `_ 7 ElMai= 0 2 o lo 2 13 1113:13 7.0 7 _ 15 153 110 1L9 a , a 20 204 16.5 t7.8 63 6 • 6 1.69 2 0 9720 - 0.9659 • •

11.fter 16 Nov 21-Now 28Nor 1-Cat 6•Dee _ 253 •

Linear r re spn ana lea t ares method for Pre- and Po -Feed Difference I .- --I Equation for the line: y nut + b 2 1M ma 5.05 b - y Intercept -2.75 2 7 standard er or value for rn 0406211 standard error value for b 1450195 11 r^2- coefficient of delermlnalicm 0.971987 The standard error for the y estmate 1.355544 4 18.5 F - F statistic value) 69.39456 df -i3Nrnes of freedom 2 ssreg - regression sum of squares 127.3125 ssresld - residual sum of squares 3.675

Table 3. Analysis of treated baby #2

I_ 22 20 20

fi 16 BABY #3 14 y - 1 2y50525•. Pro-food Peet-feed Post4 bend Difference DM trend 12 Fe - CI 3 -- (linear) (Sneer) • --, 1 13-Nov 7 8.7 3 5 3.6 to • SO 2 20-Nov 7 10 .5 9.0 35 47 3 26-Nov 11 9 2 8 0 5 7 a • a 4 4-Dec 2 8 9.6 60 7 0 • Mean 3.88 6 6 .....______------ Ski P.2 c 0.5053 Dev 2.17 I = 0.7108 ♦ • • .---_ o ,-.---- .. ---,---.-6------,- . Il -Nov 164421-Nox 26-Nor 1-044 6.04c _ 0

Linear regression analys a ( leas s o uares- method for Re- and Post-Feed phrences • DIfferences Equation for theli ne: y • ma . b 3.5 in -slope __I_ . b - y intercept 2.25 2 3.5 standard error value form 0.539843 standard error value for b 2.299456 6 .2 coefficient of determination 0.505263 The standard error for the y estimate 1.577498 _ esi 11:,I._,, 8 F - F statistic (F-observed (refuel 2.042553 yeeressidof W ssreg - regression sum of squares 7.2 rsumIornof Squares ;.7.I

Table 4. Analysis of treated baby #3

__. 1 n 2.. BABY X . la - _ is Pre-feed Post-fe•d Post-f bond Difference DM bend _Linear) OirmaN Is _ la 1 24-May 6 a o 5 r - o lss. o 44s4 2 27-Ma1 i • 5 6.2 1 0 1 3 14 14 la. - 0 8096 3 31-Mayli 4 6 7.3 20 24 8.1 3.D 3.3 4 3-Jun 5 0 -- 5 5 8.5 9.2 3.5 -52 • - _ 10 6y 10-71uurr: 8.5 10.1 35 5 2 71 14-Jun 5 12.5 11.2 7 5 6.3 a• • • B_ , 17-Jun 5 13 12.0 B 0 7.1 Mean 4.80 6 • •• •• •• •• IStd Dev 0 64 rsi 01309 4 • • _ __ 0.8808 2 2 M

23-Mw 294Any ....ham 10.Jun 16 Jun 22 Jun H 0 II _I_ . Linear regression musty, s {least squares- method) for Pre- and Post-Feed Differences I • Differences Equation for the ilne: y • nu • b I -1 IIK in -skim 0.648429 b - y Intercept _I -0.445429 siandard error value for 0.187382 standard error value for b 0.48236232 3 21 •2 - coefficient of determination 0.409555 The standard error for they esmatimatete 1.217343 • 3.0 F - F statistic (F-obserwed value) 25.5106 df - degrees of freedom 6 I 3.5 ssreg resslon sum of squares 37.52054 issreskl - residual sum of squares 8.548214 3.5 5, I T15 ILO, T i I Table 5. Analysis of treated baby #4 Summer 1998 AAO Journal/29 - t 22 20 2o Ili _ t _r_. 16 la y • 2 64 - 0 4 BABY #5 - l• 64 le o eon Pre-feed Post-feed Post-f bend Deference DWI trend - /2 ()near) (linear) 13 4Jul 3 7 51 4.0 1 i o to 2 23-Ju1 4 6 8.9 2.0 5.5 _ 1-Aug 3.5 7 5 a 4 10-Aug 3 14 13 7 110 10.3 5 15-Ain 3 5 16 15 0 12.5 11 6 6 • Mean 340 • Std Dew 042 M2= 06482 • • . • r. 0 9210 .__] 2 • _ - o 0 ------, 5-Jul 14-Jul 23-Jui 1-Aug to-aue 19-4.9 O 1 2 3 • s 6 n_ I T Linear regression analysis -leas nti res- method) for Pre- and Post-Feed Differences Differences Equation for the Ilne: y • ma • b 1 40 m -snue i 2.6 b - y intercept 1 -0.4 2 2 0 standard error value for m 0 635085 standard error value for b 2.10634 3 ].5 1,2 - coeffiaent of determination 0 648181 The standard error forthey estimate 2.008316 1 E F - F sbostre (F-observed value) 16 76033 di - degrees of freedom 3 5 2.5 ssreg - regression sum of squares 67 6 ssresid - residualsum of squares I 12.1

Table 6. Analysis of treated baby #5

_ _ _ _ _ .8 .-- In

BABY N6 y • t a• • 1 • Pre-feed Post-feed Post-1 trend Difference DM bend -- FY • 0 3704 (linear) Ili__ear • 13-A. 4 5 6 3 10 2.9 o _ . 10 2 22-Jun 2 11 8.9 9.0 5 1 • 29-Jun 5 10 10.9 5 0 fie_ 4 - 6 ..1., ]-Ju 5 14 13.1 90_ 8B - 6 5 13-Jul 4 14 14 9 10 0 10 3 6 - Mean 400 • • Std Dev 1.22 re2 = 0.5704 • - - I- r = 0.7552 2 2 --I - -- - . • - o--. --.---,.--. 10-Jun 17 -Jun 24-Jun 1-Jul 6-Jul 15 Jul 2 3 5 6

l C 1--- I Linear regression analysis leas squares" method) for Pre- and Post-Feed Differences Differen ce Equation for the line: y mx • b 1 1.0 m -slor_Li + 1.K 1:-yInterena j 1A 2 standard error value for in standard error value for Is 2.991098 _ _ __ 3 nOre2 - coeffic ant of determination 0.°679°0418231{ The standard error for tiestimate i5lirg 9.11 F - F statistic (F-observed value) 3.983607 df - degrees offreedom 5 10.0 ssregs - regression sum of squares 32.4 1- ssresld -residua! sum of squares - 424

Table 7. Analysis of treated baby #6

#2. A detailed consideration of the clinical presenta- Analysis and Discussion tion of these babies and the rationale for treatment is be- The pre- and post-feed creamatocrit reading provides a yond the scope of this article. which presents the outcomes simple. non-invasive means of assessing the effectiveness in order to assess whether a more extensive study (which of the infants sucking ability; normal infants will feed would include the above considerations as a part of any for I0 to 30 minutes and empty the breast sufficiently to ensuing report) would be worthwhile. An analysis of the obtain the hind milk (which has a higher fat concentra- outcome for the pilot study appears in the next section. tion). An infant with a dysfunctional suck (which is de- The average difference between pre- and post-feed fat es- fined as a sucking pattern which is characterised by an timation at the beginning of the month of treatment was excessive amount of up and down movements, marked 2.58mm. The average difference between pre- and post- variations in sucking rhythm. lack of characteristic rhythm feed fat estimation at the end of the month of treatment or any pattern which more subtly affects the speed, skill was II .08mm. This compares favorably with the 7.84mm or amount of milk taken at a feed) will either feed for a average for the normal infants. much shorter or longer time than infants who are feeding normally. 30/AAO Journal Summer 1998 In the former case, the feed is discontinued for a vari- Baby # t-observed t-critical Alpha=0.10 Alpha=-0.25 ety of reasons which include maternal pain and tiredness/ for pain of the infant. In the latter case, the infant may go on Alpha=0.05 sucking intermittently and ineffectually for a long time. 3.92 2.92 1.89 0.82 In both cases the infant's ineffectiveness will fail to ob- 2 tain the hind milk because the breast has not been suffi- 8.33 2.92 1.89 0.82 ciently drained. The data displayed in Tables 2 - 7 give 3 1.43 2.92 1.89 on the results of fat estimation for the 6 babies with a dys- 4 5.05 L94 1.44 0.72 functional suck. A linear regression analysis has been made 5 4.09 2.3 164 0.77 using the 'least squares' method. The regression line pro- 6 2.00 2.35 1.64 0.77 vides the best fit for the data. In each case the slope of the line measures the differences in the pre- and post-feed t-observed is calculated by dividing the regression line slope by the standard error for the slope breastmilk fat estimation per unit of time during which + t-critical values (obtained from standard statistical tables) are pre- the baby was treated. The standard error term was low, sented for both Alpha = 0.05. 0.10, and 0.25 i.e. for the probabili- varying between 0.95 and 2.99. In linear regression. an r ties of 0.05, 0.10, and 0.25 that the slope was obtained by chance. value (the coefficient of determination ) of I would indi- cate that there was no difference between the estimated Table 9 The t-critical and t-observed values for six difference between pre- and post-feed breastmilk fat esti- treated infants. mation and the actual differences. At the other extreme, if the coefficient of determination is 0, the linear regression When t-observed values are greater than the t-critical val- equation is of no value in predicting the differences. Each ues, then the probability of the slope being obtained by chance of the treated babies has an r value which exceeds 0.7. is less than the corresponding Alpha value. Therefore. there The r value for 4 of the treated babies was 0.85 or higher is less than a 5 percent probability that the slope of the re- which would be regarded as a very good outcome. In each gression line was obtained by chance for treated babies # 1, case the coefficient of determination is greater than 0.50 2. 4 and 5. less than 10 percent probability for treated baby which shows a strong relationship between the duration #6, and less than 25 percent probability for treated baby #3. of the treatment and increase in breastmilk fat estimation. Treated baby #6 was clinically a very difficult case and In 4 of the babies this is greater than 0.85 which demon- particularly successful. However, the result is skewed by strates a very strong correlation. virtue of the second pre-feed reading being uncharacteristi- cally low and the post-feed measurement being uncharac- The results of the linear regression equation for the pre- teristically high. It suggests that if a further study is done. post-fat differences is shown in Table 8 below. that twice weekly measurements should be taken so that variations like this do not have such an impact upon the statistical outcome. The mother of treated baby #2 kept a daily record Baby # Initial Final Standard error of estimator of her pain (on a scale of 0 to 10 where 0 = no pain and 10 = 1 4.2 12.2 1.5 severe pain), without being asked to do so. It was noted that 2 2.3 17.8 1.4 when she started to record a reduction in pain, the fat con- 3 3.6 7.0 1.9 4 0.5 7.1 1.0 centration in the milk increased. This tends to bear out the 5 1.8 11.6 2.1 Barowicz' contention' that maternal pain can alter the milk 6 2.9 10.3 3.0 composition. Any extension to this study should therefore include the keeping of a daily visual analog scale of mater- Table 8. Linear regression equation for the pre- nal breast pain. The fact that the average pre-post fat differ- post fat concentrations ence for the dysfunctional group is higher than for the normal group may be explained by the longer feed time and increased focus on the whole process of lactation of mothers The crucial test of the effectiveness of the osteopathic whose babies initially had breast-feeding problems. Further, treatments is whether the slope of the regression line, fit- normal babies need to be measured with an instruction to ted to the differences in the pre- post-feed fat estimates, mothers to persist in feeding from one breast for as long as increases significantly. t-statistics can be used to deter- possible. mine the probability of the slope of the regression line This pilot study demonstrates that as the infant's suck- being obtained by chance. Table 8 presents the t-critical ing becomes more effective following osteopathic treat- and t-observed values for each line. ment, a greater variance in the pre- and post-feed creamatocrit reading is seen. -,

Summer 1998 AAO Journal/31 Conclusion 17 Arbuckle B.E. (1977) The selected writings of Beryl E. Arbuckle, It appears that the milk fat estimation provides a simple, The National Osteopathic Institute non-invasive and reliable standard measurement of the 18 Lay E. (1990): Personal communication ability of an infant to feed effectively. The results with the 19. Peaker M. and Wilde C.J. (1987) Milk Secretion: Autocrine con- small sample of treated babies are encouraging. The dif- trol. News in Physiological Sciences 2:124-126 ference between pre- post-feed fat estimations of 20. Blachford D.R. and Peaker M. ( 1982) Effects of frequent milking on milk secretion during lactation in the goat. Journal of Exp. breastmilk were small in infants with a dysfunctional suck. Physiol. 67:303-310 In all but one of six cases, there was a substantial increase 21. Saint L. et al (1986) Yield and nutrient content of milk in eight in the pre- post-feed fat estimation by the end of the month women breast-feeding twins and one woman breast-feeding trip- of osteopathic treatment. All of these infants had been re- lets. Brit. J. Nutr. 56:48-58 22. Hartmann P.E. and Kent J.C. (1988) The subtlety of breast milk; viewed by a lactation consultant and all were 4 weeks or Breast feeding review. 13:14-18 older prior to the commencement of osteopathic treatment. 23. Arthur P.G.. Hartmann RE.. Smith M. (1987) Measurement of All 6 of the infants continued to breast-feed for 5 months the milk intake of breast-fed infants. J. of Ped. Gastroent and or more following treatment. At the time the infants com- Nut. 6:758-763 menced treatment each of the mothers was at the point of 24. Hartmann P.E. and Prosser C.G. (1984) Physiological basis of longitudinal changes in human milk yield and composition. Fed. discontinuing feeding. It is believed that it would be worth- Proc. 9:2448-2453 while extending the study to a cohort of 40 infants. A con- 25. Arthur P.G., Hartmann RE., Smith M. (1987) Measurement of trol group would be required to ensure validity. the milk intake of breast-fed infants. J. of Ped. Gastroent and Nut. 6:758-763 26. Henderson A.J. and Peaker M. (1984) Feedback control of milk References secretion in the goat by a chemical in the milk. Journal Physiol. JAOA = .heurnal of the American Osteopathic Association Lund. 351:39-45 27. Henderson A.J. and Peaker M. ( 1987) Effects of diluting stored I. Speiring N. (1980) Manipulative procedures used during obstet- milk on the rate of milk secretion in the goat. Journal Exp. Physiol. rical delivery. JAOA 80:219 72: 1 3-19 2. Frymann V.M. (19661 Relations of disturbances of Craniosacral 28. Egli G.E. et al ( 1 96 1 ) The influence of the number of feedings mechanisms to symptomatology of the newborn: study of 1250 on milk production. Pediatrics 27:314-317 infants JAOA 65:1059-1075. 29. Wilde C.J. et al ( 19951 Breast-feeding: matching supply with de- 3. Hussar C.J.. Retzlaff E.. Mitchell F.L., Kalhfell Briner B.J. mand in human lactation. Proc Nutr Soc (1985) Combined osteopathic and dental treatment of cephalgia. 30. Wilde C.J.. Henderson A.J., Knight C.H. Blachford D.R.. Faulkner JAW 85:605-606 A. and Vernon R.G. (1988) Effects of thrice-daily milking on 4. Magoun H.I. (1962) Osteopathic approach to dental enigmas. mammary enzyme activity, cell population and milk yield in the JAOA 62:110-118 goat. Journal Aram. Sci. 636:65-69 5. Magoun H.I. (1975) Dental equilibration and osteopathy. JAOA 31. Daly S.E.. Hartmann P.E. (1995) Infant demand and milk supply 74:981-99I Part 1: Infant demand and milk production in lactating women. J 6. Magoun H.I. ( 1973) Idiopathic adolescent spinal scoliosis: a rea- Hum Loft ll 1 I ): 21-26 sonable aetiology: The DO, 13:6-13. 32. Wilde Addey CV. Boddy LM. Peaker M (1995) Autocrine 7. Fryman!' V.M. (1976) Learning difficulties of children viewed in regulation of milk secretion by a protein in milk. Biochem J 305 the light of the osteopathic concept. JAOA 76:46-61. (Pt 151-58 8. Frymann V. M. et al (1992) Effect of osteopathic medical man- 33. Daly S.E., Kent J.C.. Owens R.A., Hartmann P.E. (1996) Fre- agement on the neurological development in children. JAOA quency and degree of milk removal and short term control of hu- 92:729 744 man milk synthesis. J Physic( 81(5): 861-875 9. Upledger J.E. (1978) The relationship between craniosacral ex- 34. Jensen R.G.. Hagerty M.M. and McMahon K.E. Lipids of human amination findings in grade school children with developmental milk and infant formulas: a review. American Journal of Clinical problems. JAOA 77:760-776 Nutrition 11978) 31:990-1016 10. Sutherland W.G. (1939) The Cranial Bowl Published by the Author 35. Boersma E.R., Offringa Pt. Muskie F.A.J. t, Chase W.M. and II. Myers R G (1997) A Review of the Literature with respect to Simmons IJ. (1991 ) Vitamin E, lipid fractions. and fatty acid com- Osteopathy in the Cranial Field. Australian Joanne! of Osteopa- position of colostrum. transitional milk and mature milk: an in- thy 8 (2 ): 13-19 ternational comparative study. American Journal of Clinical Nu- 12. Fraval M.R. (1996) Report of an Inter-rater Reliability Study of trition 53:1197-1204 the inherent motion of Cranial Bone, Australian Journal of Oste- 36. Thompkinson D.K. and Mathur B.N. (1989) Physiological re- opaths 8 (2): 4-7 sponse of neonates to lipids of human and bovine milk. Austra- 13. Sutherland W.G. (1991) Teachings in the Science of Osteopathy. lian J Nun: Diet 46:67-70 Rudra Press 37. Woodward D.R.. Boon J. and Rees B. (1989) Human milk fat 14. Graham J.M. (1981) Smith's recognisable patterns of human de- content: within feed variation. Early Hum. Dev. 19:39-46 formation. W B Saunders 38. Hartmann P.E. and Kulski J.K. (1978) Changes in the composi- 15. Miller A.W. and Callander R. (1989) Obstetrics. Illustrated tion of the mammary secretion of women after abrupt termina- Churchill Livingstone. p439 tion of breast-feeding. J. Physiol. 275 16. Magoun H.1.119761 Osteopathy in the Cranial Field. Journal Print- ing Co. Kirksville MO. 3rd Ed

32/AAO Journal Summer 1998 39. Travers M.T. Barber M.C.. Tonner E., Quarrie L, Wilde C.J., Flint 45. Ziemer M.M., Pigeon J.G. (1993) Skin changes and pain in the D.J. ( 1996) The role of prolactin and growth hormone in the nipple during the first week of lactation. J Obstet Gvnecol Neo- regulation of casein gene expression and mammary cell survival: natal Nurs 22 (3): 247-256 relationships to milk synthesis and secretion. Endocrinology 46. MacDonald H. (1995) Candida: the hidden deterrent to breast- 137(5):1530-1539 feeding. 91(9): 27-30 40. Gunn A.J., Gunn IR., Rabone D.L., Breier B.H., Blum W.F., 47. Barowicz T. (1979) Inhibitory effect of adrenaline on the oxyto- Gluckman PD. (1996) Growth hormone and breast milk volumes cin release in the ewe during the milk ejection reflex. Dairy. in mothers of pre-term infants. Pediatrics 98 (2 Part I): 279-282 Res. 46:41-46 41. Prentice A. et al Evidence for local feedback control of human 48. Francis J (1997) Breast-feeding and severe maternal pain 13 (2): secretion (1989) Biocnem. Soc. Trans. 17:489-492 100 42. Peillon F., Yuan Li J., Croissandeau G., Schussler N. (1996) Physi- 49. Lucas A., Gibbs J.A.H., Lyster R.L.J. and Baum J.D. (1978) ology of the anterior pituitary gland. Rev Prat 15: 46 (12): 1466- Creamatocrit: simple clinical technique for estimating fat con- 1471 centration and energy value of human milk. British Medical Jour- 43. Howie P.W. et al ( 1980) The relationship between suckling-in- nal 1:1018-1020 duced prolactin and lactogenesis. J. Clin. Endoc. Metab. 50:670- 50. Hudson G.J., Gerber H. and John P.M.V. ( 1 979) Creamatocrit 673 procedure versus triglyceride analysis: a comparison of methods 44. Cox D.B., Owens R.A., Hartmann P.E. (1996) Blood and milk for the determination of human milk fat in epidemiological stud- prolactin and the rate of milk synthesis in women. Exp Physiol 81 ies. J. Human Nutr. 33:283-287 (6):1007-1020

1998 AAO Convocation Remembered, Revisited Renewed VIDEO TAPES AVAILABLE Cat# Title Speaker #039801 Anatomical and Histological Evidence of Somatic Dysfunction Frank Willard, PhD The Anatomy of the Lympathics Frank Willard, PhD #039802 The History of Manipulation: Ancient times to 1874 John M. Jones, Ill, DO The History of Manipulation: 1874 to the present John G. Hohner, DO #039803 Nociception and the Persistence of Somatic Dysfunction Richard L. Van Buskirk, DO, FAAO Concepts of Somatic Dysfunction; then and now Irvin M. Korr, PhD #039804 History and Development of Lymphatic Techniques Hugh M. Ettlinger, DO Cranial Biomechanics and the Progress of Knowledge since Sutherland Patrick M. Coughlin, PhD #039805 The OMM Specialist: History and Ramifications Anthony G. Chila, DO, FAAO The History and Utilization of Orthotic Devices Michael L. Kuchera, DO, FAAO #039806 Andrew Taylor Still in Print: What is the Legacy? Raymond J. Hruby, DO, FAAO Parallel and Distinctive: Perspective from Three Years Later Norman Gevitz, PhD #039807 The Application of Osteopathy to Children Jane E. Carreiro, DO American Systems of Manual Medicine: Historic and Current Perspectives Marvin Wieland, DC, DO #039808 Osteopathic Physicians in the Military R. Todd Dombroski, DO Osteopathic Psychiatry David A. Baron, DO Women in Osteopathy Melicien A. Tettambel, DO, FAAO

Tapes are recorded in U.S. standard VHS format, call for a VHS video tapes of the 1998 AAO Convocation are now quote to convert to overseas format. available for your personal library at a special Convocation discount of $195.00 + shipping for the full set of (8) tapes. Program Chairperson Dennis Dowling arranged the program For order form, contact: around the theme "Remembered, Revisited & Renewed." AMERICAN ACADEMY OF OSTEOPATHY The Academy hired a professional contractor to tape these 3500 DePauw Boulevard, Suite 1080 lectures. Please review the titles and order your complete Indianapolis, IN 46268-1136 set. You may also order individual copies of tapes which Phone: (317) 879-1881 or FAX (317) 879-0563 pique your interest.

Summer 1998 AAO Journal/33