1050 Review Article

Osteopathic Manipulative Treatment in Pediatric

and Neonatal Patients and Disorders: Clinical
Considerations and Updated Review of the
Existing Literature
Donatella Bagagiolo, DO1 Alessia Didio, DO1 Marco Sbarbaro, DO1 Claudio Giuseppe Priolo, MD2
Tiziana Borro, MPH2 Daniele Farina, MD2

1 Research Department, Scuola Superiore di Osteopatia Italiana, Address for correspondence Donatella Bagagiolo, DO, Research
Torino, Italy Department, Scuola Superiore di Osteopatia Italiana, Piazza Bernini,
2 Division of Neonatology and NICU, Sant’Anna Hospital, Azienda 12, 10143 Torino, Italy (e-mail: donatella.bagagiolo@libero.it).
Ospedaliera Regina Margherita Sant’Anna, Torino, Italy

Am J Perinatol 2016;33:1050–1054.

Abstract Osteopathic medicine is a form of complementary and alternative medicine. Osteo-

pathic practitioners treat patients of all ages: according to the Osteopathic International

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Alliance’s 2012 survey, about one-third of all treated patients are aged between 31 and
50 years and nearly a quarter (23.4%) are pediatric patients, with 8.7% of them being
younger than 2 years. In 2013 a systematic review evaluated the effectiveness of
osteopathic manipulative treatment (OMT) in pediatric patients with different underly-
ing disorders, but due to the paucity and low methodological quality of the primary
studies the results were inconclusive. The aim of this review is therefore to update the
evidence concerning OMT in perinatal and pediatric disorders and to assess its clinical
impact. Most published studies favor OMT, but the generally small sample sizes in these
Keywords studies cannot support ultimate conclusions about the efficacy of osteopathic therapy
► osteopathic in pediatric age. In turn, clinical trials of OMT in premature infants might represent an
manipulative important step in the osteopathic research because they can address both cost-
treatment effectiveness issues, and an innovative, multidisciplinary approach to the management
► pediatric of specific pediatric diseases cared for by the same, common health care system. The
► preterm available studies in neonatal settings provide evidence that OMT is effective in reducing
► positional the hospital length of stay of the treated infants, therefore, suggesting that robust cost-
plagiocephaly effectiveness analyses should be included in the future clinical trials’ design to establish
► infantile colic new possible OMT-shared strategies within the health care services provided to
► cost-effectiveness newborns.

Osteopathic medicine is a form of complementary and alter-
native medicine, an approach that incorporates medical and
scientific knowledge to apply a range of manual techniques
for assessment, diagnosis, and treatment.1,2
One important component of osteopathic health care is
osteopathic manipulative treatment (OMT), which refers to
an array of many types of manipulative techniques, with
the aim to solve somatic dysfunction (the International
Classification of Diseases, Tenth Revision, Clinical Modifi-
cation Diagnosis Code M99.00–09) defined as impaired or
altered function of related components of the somatic
system: skeletal, arthrodial, and myofascial structures,

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 OMT in Pediatric and Neonatal Patients and Disorders
and their related vascular, lymphatic, and neural
elements.3
Osteopathic practitioners treat patients of all ages; accord-
ing to the Osteopathic International Alliance 2012 survey,
about one-third of all patients were between 31 and 50 years
of age and nearly a quarter (23.4%) were pediatric patients,
with 8.7% of them being younger than 2 years.2
A single study has described and detailed the character-
istics of the pediatric population and their use of OMT in the
United States. This retrospective analysis reported a total of
407 patients who received 1,500 visits: their age profile
showed that almost half (46%) of the children were younger
than 5 years. Diagnoses covered a wide variety of common
pediatric conditions; of note, up to 43.5% of the patients were
referred to OMT for nonmusculoskeletal diagnoses (head-
ache, otitis media, asthma, upper respiratory infection, feed-
ing problem, gastrointestinal disorders).4
This retrospective study is in accordance with the litera-
ture, where the impact of OMT in respiratory dysfunction,
cerebral palsy, deformational plagiocephaly (DP), and recur-
rent acute otitis media is consistently reported.5–8 In 2013, a
systematic review has evaluated the effectiveness of OMT in
several pediatric conditions, but due to the paucity and low
methodological quality of the primary studies, the results
appeared inconclusive.9
After that publication, though, a few studies assessed the
effect of OMT in preterm children—aiming at assessing the
impact of OMT on medical outcomes such as the length of stay
(LOS), feeding, and gastrointestinal function.
The present review aims at updating the evidence con-
cerning OMT in perinatal and pediatric conditions, and its
clinical impact.
Osteopathic Manipulative Treatment in
Different Pediatric and Infant Conditions: An
Overview
Preterm Infants
Prematurity is defined by the World Health Organization
when childbirths occur before 37 completed weeks of gesta-
tion. According to estimates, 14.9 million babies are born
preterm every year.10
Complications of preterm birth are the single largest direct
cause of neonatal death, responsible for 35% of the world’s 3.1
million yearly deaths, and the second most common cause of
deaths after pneumonia in infancy. Preterm infants need to
attain medical stability, physiological maturity, including
adequate temperature control, cessation of apnea, and bra-
dycardia and feeding behavior before discharge from the
hospital can be deemed appropriate and safe.11
The economic costs of preterm birth are important in terms
of the immediate neonatal intensive care unit (NICU) admis-
sion and stay, and of the ongoing long-term complex health
needs. LOS is one of the major clinical outcomes to assess and
rate the effectiveness of interventions in NICU settings.12,13
With regard to this parameter, OMT has been documented
effective in reducing LOS in a limited number of clinical
trials.13–15
Bagagiolo et al. 1051
Cerritelli et al randomized 110 preterm infants in two
groups: 55 who underwent OMT and 55 who underwent
standard pediatric care.15 Osteopathic service was provided
twice a week until patients reached the stability of the
physiological condition (maintenance of body heat at room
temperature, coordinated sucking, swallowing, and breathing
while feeding). The findings showed that there was a signifi-
cant association between OMT and LOS reduction with a
mean difference between treated and control group of
5.9
mean days less (standard deviation:  3.869; p < 0.01). Cost
analysis considering the entire study period estimates a net
saving using ordinary least square of €139,044.30 (range:
€93,237.19–184,851.00).
Another trial was conducted by Pizzolorusso et al. Several
110 preterm infants were randomized to receive either OMT
or routine pediatric care. Here again, the OMT group showed
shorter hospital stay (
2.03 mean days; p < 0.01) compared
with the control group. Cost analysis showed that OMT
significantly provided a net saving of €740 per newborn
per LOS.14
In 2015 a multicenter, randomized controlled trial (RCT)
enrolled 695 preterm newborns between 29 and 37 weeks
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gestational age from three different public NICUs. The infants
were randomly assigned to either OMT group (n ¼ 352) or a
control group (conventional care; n ¼ 343). There was a
statistically significant reduction in LOS, this last being 13.8
mean days for the OMT group versus 17.5 mean days for the
control group, respectively (p < 0.001). At multivariate anal-
ysis, a reduction of the LOS of 3.9 mean days was shown and
retained statistical significance (p < 0.01). Concerning the
costs per infant, the study reported a significant difference
between the OMT and control group equal to €1,586.01
savings (p < 0.001).13
The effect of OMT on gastrointestinal function and LOS
were investigated through a prospective, nonrandomized,
cohort study in 350 consecutively born neonates. Of them,
188 were assigned to standard care, while 162 received
routine care plus OMT. Multivariate logistic regression re-
ported OMT to be independently associated with a 55%
reduction of gastrointestinal symptoms. Similarly, an inde-
pendent effect of OMT was seen on LOS, which was reduced by
more than 75% in the study group.16
Premature newborns and infants need to have a successful
transition from gavage to nipple feeding using breast or bottle
before discharge from the hospital. Delayed acquisition of
these skills may result in prolonged hospital stay till such a
competency is achieved. In a case report study, two twin girls,
born at 25 weeks þ6 days of gestational age, were provided
with OMT sessions due to nipple feeding dysfunction.17 The
two twin infants had been already proposed for surgical
placement of gastrostomy tubes due to their inability to
take all feedings by nipple suction. Nonetheless, a series of
evaluations and OMT sessions were performed before surger-
ies were scheduled, and these treatments improved consid-
erably the infants’ ability to feed by nipple suction, so that
surgeries could be postponed and ultimately the two infants
could be safely discharged home when they were 43 1/7 weeks
gestational age old.
American Journal of Perinatology Vol. 33 No. 11/2016
1052 OMT in Pediatric and Neonatal Patients and Disorders
Infant Conditions Other Than Prematurity:
Miscellaneous
Another case report study described a newborn, 12 days old,
with severe bilateral congenital talipes equinovarus. He was
treated with two short-leg serial casting in combination with
four OMT, with restoring of the mobility and correction of the
deformities of both the lower limbs.18
The positive effects of OMT reported so far cannot be
confirmed so far in constipation and difficult meconium
evacuation, a condition that is critical for achieving and
maintaining good oral feeding tolerance and adequate gas-
trointestinal function. A prospective, randomized pilot trial
was performed in a single NICU to evaluate the effects of
visceral osteopathic manipulative on the velocity to complete
meconium excretion and on improving feeding tolerance.
Some 41 infants with birthweight < 1,500 g and gestational
age < 32 weeks were assigned to an OMT group (n ¼ 21) and
to control group (n ¼ 20). The results showed no significant
differences between the two groups in terms of passage of
last meconium. Time to full enteral feedings was 8 days longer
in the intervention group, with a median of 34 days, than in
the control group was 26 days, which was significant.19
Infantile Colics
Infantile colics are a common cause of paroxysmal abdominal
pains, occurring frequently in infants in the first 3 months of
life and affecting up to 40% of them.20 Etiological factors
include an incomplete lactose absorption, cow’s milk intoler-
ance, familiar and genetic factors, intestinal microflora dis-
turbances, as well as dietary insults. Stress factors in
pregnancy, childbirth, and inadequate postnatal care may
also be important determinants in the development in infan-
tile colics. The effect of OMT was investigated through a
controlled prospective study: 28 infants between 1 and
12 weeks of age were randomized to either cranial osteo-
pathic manipulation or no treatment. Results showed a
significant reduction between weeks 1 and 4 in crying times
(hours/24 hours) (p < 0.001), recorded by the parents
through the compilation of a daily diary, where parents
recorded the times spent in crying, sleeping, and being
held/rocked.21
Plagiocephaly
DP is a nonsynostotic deformation of the head that results
from external forces that mold the skull in the 1st year of the
life.22,23
DP may be detected in up to one of five infants during the
first 2 months of life.
Risk factors for DP include prematurity, prolonged labor,
unusual birth position, assisted delivery, twins, first-born
child, neck problems, maternal age (> 35 years), and male
sex.24,25 The prevalence of DP is related to the age of infants,
and changed over time after the educational campaign “Back
to Sleep”—being now estimated to occur in 16% of the infants
aged 6 weeks, 19.7% at 4 months, 6.8% at 1 year, and 3.3% at
2 years of age.22,26
Of note, 4 months is the critical age for the development of
DP.22
American Journal of Perinatology Vol. 33 No. 11/2016
Bagagiolo et al.
Early assessment and diagnosis of nonsynostotic deforma-
tion is an essential part of management not only for the shape
of the skull, but also for possible clinical significant differ-
ences in gross motor development, such as sitting up, rolling
back to side, crawling, neck muscle dysfunction, and low or
variable tone.27–29 An association between DP and mandibu-
lar asymmetry has been observed. This deformity seems to be
secondary to rotation of the cranial base and anterior dis-
placement of the temporomandibular joint not resulting from
primary mandibular deformity.30 Therapeutic decisions and
DP managements may vary according to the severity of DP
and the timing of treatment. Studies suggest that earlier
interventions are more effective than later treatment.31–33
The effect of OMT in DP is documented in a pilot study that
reveals a 50% mean reduction in asymmetry in 12 infants who
undergo a course of four osteopathic treatments (60 minutes
each) scheduled 15 days apart (  4 days).8
Discussion
Here, we reviewed the scientific evidence supporting the use
of OMT in several infant/pediatric medical and osteoarticular
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conditions. Most available studies show favorable evidence
supporting OMT, but the small sample sizes cannot vouch for
an ultimate, statistically significant efficacy of osteopathic
therapy.8,17–20
OMT clinical trials in preterm neonates may represent an
important step in osteopathic research because they may
address both cost-effectiveness issues and sustainability in
terms of cooperation within different services of the health
care system.13–15
These studies, evidence that OMT is effective in reducing
LOS in preterm infants in NICU. In a multicenter RCT, the net
saving associated with reduced LOS was about €1,600 per
newborn, determining an overall net saving for the whole
NICU of more than €500,000 during the 14-month study
period.13 Consistent with the results from the previous
single-NICU studies, the three available RCTs report different
extents of reduction in LOS, clearly secondary to the different
populations enrolled in the three different studies—as an
example, one multicenter trial included both low-birth-
weight infants as well as moderate and late preterm infants,
whereas the two other RCTs enrolled moderate and late
preterm newborn only.
To date, the only RCT showing no favorable results of infant
OMT was performed to evaluate the effect of visceral osteo-
pathic manipulative practices on meconium excretion.19 Two
aspects must be underlined: first, the small sample size may
have prevented the detection of significant effects; second,
and most importantly, the visceral osteopathic treatment
performed in that trial followed a protocol that was adapted
from an original protocol of visceral OMT in adults—thus
possibly not fully suitable for preterm infants.
A recent study proposed the development of a specific
model to apply as evaluation and treatment for the osteo-
pathic care to fit the specific preterm and term infants’
needs.34 In this context, the visceral approach was not in
direct contact with the organ. The authors assume that a
 OMT in Pediatric and Neonatal Patients and Disorders
direct approach in newborns could be dangerous because of
their fragile condition as the small size of infant anatomy
makes osteopathic practitioners unable to perform tradition-
al approaches. In addition, when considering the medical
semiotics there is no examination that allows a direct and
specific palpation of the visceral structure.
Further studies concerning osteopathic treatment in in-
fants with meconium evacuation-related disorders are re-
quired, as well as the development and assessment of
different protocols specifically considering the peculiar phys-
iological conditions of these unique patients.
As for safety, no adverse events were ever reported in the
studies on osteopathic treatments in infants, with these
management approaches being generally well tolerated.
Conclusion
The above summarized updated evidence on the role and
indications of OMT in neonatal and infant age provides data
supporting the feasibility of OMT practices in several infant
and pediatric conditions.
Nonetheless, there is a clear need for adequately designed
cost-effectiveness studies, with the aim to unveil the impor-
tance of a formal integration of osteopathic treatment strate-
gies within the framework of the neonatal standard of care
provided by national health care systems.
New, important data in this area are expected to emerge in
the next years, thus covering the current knowledge gap in this
area, and hence marking a potentially valuable step forward
toward full adoption of such strategies in the nurseries.35,36
Conflict of Interest
None.
Acknowledgments
The authors would like to thank Dr. Paolo Manzoni for
critically reviewing this article and Silvia Daccò for her
helpful advice and suggestions.
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