Facilitiating-a-growing-anatomy

Paediatric Care – Facilitating a growing anatomy

The considerations and professional knowledge base for treating babies and children are immense. Osteopaths need to take into account the vulnerability and changes of their emerging anatomy and physiology. Knowledge on when and what changes are made through growth, use, trauma, disuse, and disease is needed to determine the appropriate gentle, hands-on treatment. Hilary Percival shares some of the factors that influence children’s growing anatomy that need to be considered when treating this younger age group.

The osteopath’s role

The osteopath’s role is to free the anatomy so that the baby and child can grow unhindered and develop healthy, meaningful movement patterns that will serve them well for the rest of their lives. When we are treating infants and children we have to intimately understand where their anatomy has started embryologically, the journey the anatomy has made thus far and the development that is still to come. It is not only the outline of prescribed genetic development that is important (for example how the tibia is going to grow and how long) but also the changes that quality of use and movement make, including the impact when movement is interrupted by disuse from illness, injury or neurological compromise before it is fully formed.

Understanding the developmental anatomy is critical to judging the type and amount of pressure that may be safely applied, making a detailed understanding of the changing structure of the growing body a foundational area of knowledge for the treatment of babies, children and adolescents.

As osteopaths we are uniquely placed, when we understand the anatomy in this way, to make changes that allow the body to grow in a more efficient way which is kinetically beneficial to that person for the rest of their life. This may be in encouraging good anatomical relationships between the bones in their many parts before they fuse or in removing the stress from the body when it has been injured or unable to move freely for whatever reason. The child then needs to make meaningful use of their anatomy to make good neuronal connections that last a lifetime. Then the structure will govern the function but up to that time we have the facility to influence the way the body is growing and developing.

The parts of the anatomy that are made for growth are also the very windows that osteopaths can use to aid their treatment. This short article touches on a fraction of the changes that are possible and that can occur. I hope that from here you can further aspire to study the effects of growing and journeying through childhood, allowing a greater understanding of why adult bodies have formed as they have and how to safely and effectively help children along the way.

Structure governs function

Structure governs function in an adult but in a child its functional use creates the dynamic form of the body.

An infant’s and child’s growing anatomy is a hotbed of activity, a dynamic soup which can develop and change according to the genetic pattern and the environment the child journeys through. The meaningful use of our bodies changes the structure right from conception. As it happens before the body has its adult shape, it provides the future function – in shape and form and our ability to use our bodies in a free and energy efficient way. When the body is well formed it can perform its tasks with effortless ease, it gets less tired and is less prone to injury and disease.

It can be likened to a murmuration of starlings that changes its form and focus as a shape-shifting cloud.

Andrew Taylor Still said ‘Structure governs function’ but in a child, because the structure is developing, the functional use creates the dynamic form of the body. This early use allows the body to set its own course of development not just in terms of ability to move in a certain way but much more fundamentally in the form and shape the structure takes. This then allows for the way we can use our bodies in adulthood.

The body is ingenious in its formation, allowing for areas of growth and change. The parts of the anatomy that are made for growth are also windows that osteopaths can use to aid their treatment. This is especially prevalent during childhood. Every system has an in-built part of it that can grow, adapt and change to create the adult form. It is generally accepted that there are windows of opportunity that allow for the maximum efficient change to happen. You may have come across this when treating plagiocephaly with cranial osteopathy. The cranium’s ability to change shape easily with treatment is generally considered to be greatest before 14 months of age. That is not to say that you cannot change head-shape after that time, it is just slower and harder to achieve.

Movement before birth

A foetus in utero must move to use its emerging form to prepare for life outside the womb. If you have a pair of twins in utero, usually one twin is bigger than the other and can move more easily. The twin who moves less and less often starts in the outside world at a disadvantage and has more hurdles to get over to develop function, as in starting to move against gravity, and in starting to feed and kick. The baby who is in an in-utero environment where there is less amniotic fluid (Oligohydramnios) will be compressed and the quality of their movements will be affected. (Ianiruberto and Tajan 1981, Rosier van Dunne et al 2010)

The human form is clear by week twelve or before and there is function. A mother feels quickening or foetal movements from as early as 13 to 16 weeks, depending on whether she is a prima or multigravida. This is one of the oldest methods of monitoring foetal well-being in the second and third trimesters of pregnancy. The quality and quantity of these movements has been studied for the assessment of the condition of the nervous system, which we now call normal development or developmental milestones.

Involuntary isolated limb movements have been seen and recorded in preterm and full-term infants (Fukumoto et al 1981; Grigg-Damberger 2016). Unilateral hand movements have been shown to elicit a response in somatotropic electro-encephalopathy (EEG) activity in the area overlying the contra-lateral frontal scalp area while bilateral movements of the body give symmetrical EEG activity. This meaningful development is creating brain cells and allowing connections to be made. (Mihl et al 2007. Losito et al 2017.) This suggests that muscle contractions happening on a regular basis provides afferent signals to the developing cortex allowing refinement of body mapping in the brain.

Effect of birth

Birth is an event. The infant is subjected to moulding of the head and body (Ami et al 2019) which may persist after birth and can impact on the infant in many ways. The body uses mechanisms to correct the moulding that has impacted it such as the first breath, sucking and crying, though the results can be only partially effective. As osteopaths we often witness in the really unsettled babies that head moulding is persistent even after four weeks post birth and that many of their symptoms of crying and not sleeping well can resolve as the head remoulds after osteopathic treatment. (Hayden 2006).

The way the baby is able to position itself for a vaginal birth, (such as left occiput anterior, asynclitic, occipito-frontal or breech) as well as the length of the birth process, the experience of the mother (first or subsequent birth) and whether intervention (such as forceps, ventouse or c-section) has been needed all leave their story upon the infant’s anatomy. Their recovery from this and the quality of their recovery have impacts on the anatomy. For example if the baby struggled to turn in the birthing process (when they were head down for delivery) their zygomae and maxillae could get compressed which might change the shape of the eye-socket and the palate. This could lead on to problems with eyesight or with dentition such as to a cross bite.

The effect of birth can be obvious such as in the box below or maybe more insidious and not show up until the child misses a developmental milestone. Asymptomatic brain haemorrhages and retinal haemorrhages occur in 43% of vaginally delivered neonates (Rooks VJ 2008). The effects can be functional such as a breech baby who missed their sitting milestone because their innominates have not recovered from being pushed inwards and therefore are not wide enough to provide a good base for sitting, or they can be more pathological in the way they impact on the development of the anatomy from there onwards.

The effects of birth could leave the baby with the following:-

  • Torticollis
  • Plagiocephaly
  • Cranial head moulding
  • Palsy of a limb
  • Shoulder dystocia
  • Asymptomatic brain haemorrhages
  • Symptomatic brain haemorrhages
  • Retinal haemorrhages

Handling and moving after birth

The way that we are handled when we are unable to physically move ourselves makes a great deal of difference. If a baby is picked up under the

armpits their shoulder girdles shift up round their ears. This is bad enough if you are healthy but if you have sustained a mild birth injury and your cervical spine is tighter than it should be this will give pain and dysfunction and can cause the baby to resist moving. A baby who does not move is not making all those good neuronal connections. Another example is where a baby who has reflux and its mother is told to keep the baby upright.

Such a baby is often placed over the mother’s shoulder with its legs dangling down, and the baby then struggles to make a good connection with their own abdominals and diaphragm, and the immature lumbar spine is impacted by being pulled out of its C-curve (which in my opinion leads to poor function in the lumbar spine and can be one of the contributing factors to bum shufflers rather than crawlers). The baby will also probably not be allowed tummy time for fear of it being sick. The baby’s diaphragm remains high and in my experience the diaphragmatic sphincter at the top of the stomach does not work well in this position and the baby is likely to have a rectus abdominus diastasis which may predispose them to a life time of reflux and dysfunction.

The opportunity to move from birth onwards

There is anecdotal evidence from primary school teachers that that there is a relationship between immature motor skills and educational under achievement. Opportunities for active play in the first three years of life are critical for development of the neurone pathways of the central nervous system and muscles which impact also on the bony skeleton development. Poor neuro-motor development in motor milestones such as sitting un-aided and crawling can lead to delay in fine and gross motor skills that can be seen in school age children. Crawling contributes to many other areas of development as it is an opportunity for a movement that crosses the midline and uses a pathway that uses both sides of the brain in a co-ordinated way via the corpus collosum. This has an on-going effect in later life in how the child copes with stress and problem solving. Crawling uses all the major muscle groups for co-ordination and stabilisation. (McEwan et al 1991). As osteopaths we need to make sure that we know all the milestones of development and that if a baby is not reaching those that we make an enquiry of their body as to why not. Is a child who is not crawling at ten months a child who has not built up adequate strength in their shoulder girdle, pelvic girdle and abdominals? Is there a problem in the lumbo-sacral joint being is too stiff to allow the legs to come under the body? Is there a central nervous system issue etc?

An infant and child who has deficient motor development such as missing important milestones in the early part of life can develop vision/spatial problems. There is a link between reading difficulties and the ability of a child to control their motor system of movement. Sigmundsson et al (1997).

Stimulation of nerve pathways in the skin, the eyes, the muscles and the vestibular system support all the aspects of early childhood development. Physical movement of the body provides stimulation for all these systems which in turn supports and enhances emotional, intellectual, social and physical growth.

Bones

Infants’ and children’s skeletons are more elastic than those of adults. The long bones have growth plates. The joint surfaces and interfaces in young children are vulnerable to compressive forces. This makes them more susceptible to injury, including from the application of force in manual therapy techniques. However, it also gives a window of opportunity for significantly improving function, for example in a knee joint in an under-eight-year-old where the joint is still malleable and can adapt more easily to change. It works both ways, making a detailed knowledge of the timings of bony ossification critical to treating children safely, whilst also in many cases being key to treating them effectively.

The cranial vault bone sutures are not interdigitated at first, gaining the intricate sutural pattern as the brain finishes its growth. The sutures serve as growth centres, sites of ostoegenesis for the face and skull vault and they provide a place of adaptation during birth and a place of focus for the cranial osteopath. The cranial bones are also in parts: the parts of the occiput, temporal, frontal and sphenoid all fuse at different times in childhood. The growth plates are vulnerable to change from fractures, injury, tumour, irradiation or repetitive stress. Cunningham et al (2016) note that as bone develops it must accommodate the changing stresses that are put upon it. This helps shape it and define the bony structure. All bones respond to activity and stresses placed upon them, especially when they are still growing and changing. A young child who does forty minutes of normal vigorous activity will have significantly stronger bones than their less-active peers.

The growing child has more bones because the parts are not yet fused. So, for example the acetabulum has a triradiate shaped cartilage where the three bones of the pelvis are held together by cartilage which ossifies at between 11 to 16 years of age in females, and 14 to 18 years in males (Cunningham et al 2016). This allows the acetabulum to expand in size as the child grows and as the head of the femur also expands. However, it also allows for trauma to disarrange the cartilage and impose a restriction or overlapping between the meeting of the bones. This can impinge on the free movement of the femoral head in the acetabular cup leading to pain and dysfunction. Furthermore, one of the blood supplies to the femoral head is the artery of the ligamentum teres which comes in between the triradiate cartilage and can be impinged leading to necrosis of the femoral head (Perthes disease). This very design that allows growth also allows us as osteopaths to address any strains before the bone ossifies into its fully grown adult shape.

The respiratory system

The diaphragm is one of the first muscles to activate in utero. It is imperative that it boosts up at birth and this activates the all-important first breath. The first breath expands the lungs and the quality of that is important in the quality of breathing for the infant. As osteopaths we find that children who have had a poor quality first breath are more likely to be the child who does not sleep well at night.

Babies are obligate nose breathers. In practice you can see how much a baby struggles to feed if it cannot breathe through its nose as part of the suck-swallow-breathe sequence. Nasal breathing also provides a feedback loop to thoracic ventilator movements. If the baby cannot nose breathe it can lead to deficiencies in thoraco-abdominal ventilator movements. Nose breathing is also critical for development of nasal sinuses so changing the oro-facial morphology and function. The face grows extensively in the first two years of life postnatally.

Nasal breathing has been found to change the development of the anterior part of the maxilla which is fundamental in the position of the anterior teeth. Other changes have been noted by Guilleminault in the narrowness of the posterior nasal fossa and to abnormal saggital growth of the maxilla which impacts on the development and expansion of the maxillary sinuses.

The developing palate can be affected by interfering with lack of airflow. The normal periosteum reabsorption can become impaired which means that the normal physiological lowering of the inferior portion of the nasal fossae does not happen. This leads to a lack of vertical height of palate with narrowness which in cranial terms is called an extended palate. The tongue then does not fit into the roof of the mouth and help keep a nice wide “u” shape and ultimately that person may be more prone to Otitis media. Guilleminault (2017) notes that if one side of the nose is obstructed there is asymmetry in the vault of the palate which effects teeth orientation. Lack of nasal breathing can also leads to the lack of development in the maxilla dental arch so that no diastasis appears between the deciduous teeth ahead of the placement of the permanent teeth. This leads to crowding of the adult teeth.

Conclusion

This article is just a teaser, a mere drop in the ocean, compared with the complexity of development that goes on in all parameters from infancy to adulthood. Maintaining good movement is key to healthy outcomes in the developing child from the cell level to bones, muscles, posture and ultimately the individual’s capacity to live and function freely and efficiently at all levels. There is much to know and probably much more yet to be discovered. For us as osteopaths, it is simply a question of exploring the many factors that can affect the growth and development of our bodies in every parameter. Every patient provides another opportunity to learn something new. And therein lies the joy and the great privilege of osteopathy. Have fun digging on!

Hilary Percival

Hilary studied at The British School of Osteopathy (1988) spending as much time as she could in the Children’s clinic. For the last 33 years she has spent most of her practising life in Clitheroe, Lancashire treating babies and children while honing her skills with the likes of Susan Turner, Viola Fryman, and Jane Carriero. A national and international educator of paediatric osteopathy working for Sutherland Cranial College of Osteopathy and European School of Osteopathy, she has helped head the team that successfully set up the SCCO paediatric Diploma, now in its third cycle.

References

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Grigg-Damberger MM. The visual scoring of sleep in infants 0-2 months of age Clin sleep Med 2016 :12429-45

Mihl M, Kaminska A, Huon C, lapillonne A, Ben-Ari Y, Khazipov R. Rapid cortical oscillations. Cerb cortex 2007; 17:1582-94

Losito E, Eiserman M, Vignolo P, Hovhannisyan S, Magny JF, Kaminska A. Benign neonatal sleep myoclonus evokes somato- sensory responses. J. Clin Neurophysiol 2017; 34:484

Roseir van Dunne et al. Fetal general movements and brain sonography in a population at risk for preterm births. Early Hum dev 86:107-111

Ianniruberto A, Tajani E. (1981) Ultrasonographic study of foetal movements. Semin Perinatal 175-181

Guilleminault C, Huang Y-s, From oral facial dysfunction to dysmorphism and the onset of paediatric OSA, Sleep Medicine Reviews (2017)http://dxdoi.org/10.1016/j.smrv.2017.06.00

Cunningham C,Scheuer L,Black S 2016 Developmental Juvenile Osteology Pub Elsvier

Sigmundsson H , Ingvladsen RP, Whiting HT, Inter and intra sensorymodality matchingin children with hand eye co ordination problems. Developmental medicine and child neurology 39(12),760-6

Ami O, Maran JC, Gabor P, Witacre EB, Musset D, Dubray C, mage G, Boyer L. May 15 2019 Thjree dimensional Magnetic resonance imaqing of fetal head molding and brain shape changes during the second stage of labor. https://doi.org/10.137/journal.pone 0215721

Hayden C, Mulinger B, A preliminary assessment of the impact of cranial osteopathy for the relief of infantile colic Complementary Ther Clin Pract 2006 May ;12(2) 83-90

Rooks VJ Eaton JP, Ruess l, Peterrmann GW,Keck-wherleyJ, Pedersen RC Prevalence and evolutionof intracranial hemorrhage in asymptomatic term infants AJNR Am neuroradiol. 2008 1082-1089

McEwan M, Dihoff R, Brosvic G , (1991) Early Infant Crawling experiences is reflected in later motor skills development, perception and motor skills. Newcomb medical centre, Temple university 72(1) 75-79

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