Andrea Manzotti, Alessia Alati, Matteo Galli, Francesco Cerritelli, Chiara Leva, Adele Alberti, Alessandro Stizzoli, Sara Costanzo, Carlotta Paola Maria Canonica, Francesca Destro, Gianvincenzo Zuccotti, Valeria Calcaterra, Gloria Pelizzo | Year 2022

Postoperative Osteopathic Manipulative Treatment in Children with Esophageal Atresia: Potential Benefits on the Anthropometric Parameters

Pathology:

Esophageal atresia

Type of study:

case series

Date of publication of the study’:

2022/Oct/20

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Purpose of the study

  • Objective: to describe the use of OMT in 5 children operated for type C esophageal atresia in neonatal age
  • Measured outcomes: evaluation of the range of motion (ROM) of the right shoulder, of the body mass index (BMI), weight and height

Participants

  • Number: 5
  • Description: 5 children (1 female and 4 males) who underwent surgery following a diagnosis of type C esophageal atresia.

5-year-old child, born at term by eutocic delivery. Right lateral thoracotomy with muscle sparing approach on day 2 of life after a diagnosis of EA with distal fistula, which was followed by two endoscopic dilations. Frequent episodes of reflux treated pharmacologically, more than 3 respiratory infections per year and some episodes of dysphagia with solid foods.

5-year-old girl, born by cesarean delivery. Right lateral muscle-sparing thoracotomy on day 2 of life after a diagnosis of EA with distal fistula. She also had a drainage of the upper left vena cava in the left atrium and sacralization of the first coccygeal vertebra with absence of the others. Many episodes of gastroesophageal reflux treated with specific medications and by modifying night posture. More than 3 respiratory infections per year.

3-year-old boy, born preterm. Right lateral thoracotomy with a muscle sparing technique 9 months after birth after a diagnosis of type C esophageal atresia, followed by 3 endoscopic dilations for esophageal stenosis. Rarely showed gastro esophageal reflux (for which no particular drugs had been used). A maximum of 3 episodes of respiratory infections per year.

A 3-year-old boy, born through vaginal delivery, small for gestational age (SGA) with an Intrauterine Growth Restriction (IUGR). Right lateral thoracotomy after diagnosis of esophageal atresia with tracheoesophageal fistula on day 2 of life, followed by respiratory failure. A fundoplication was performed one year and 7 months after birth to treat gastroesophageal reflux that did not respond to medications. He underwent 8 endoscopic dilations during routine follow-ups. More than 3 respiratory infections a year, he followed a specific diet and often had symptoms of food stuck in the esophagus.

Child of 7 years, born from eutocic birth at 39 weeks of gestation. Lateral thoracotomy with a muscle sparing approach the day after birth following a diagnosis of esophageal atresia with tracheo-esophageal fistula. Some reflux episodes treated pharmacologically and less than 3 respiratory infections per year.

Interventions and evaluations

  • Assessment of weight, height, BMI and ROM of the right upper limb in elevation through a manual goniometer before each treatment.
  • 6 OMT sessions within a maximum period of 4 months.
  • OMT:
    • assessment of resistance to passive movements and detection of somatic dysfunctions (non-homogeneous and non-compliant areas) and restrictions in areas such as hyoid, larynx, esophagus, sternum, ribs and diaphragm (areas involved in atresis and surgery)
    • customized treatment aimed at: restoring the physiological ROM by improving the movement of scars, ribs, sternum, vertebrae, superficial cervical fascia, hyoid, larynx, diaphragm and upper limb; improving breathing capacity and swallowing
    • Actual OMT interventions: joint mobilization, soft tissue techniques, myofascial release, balanced ligamentous techniques (BLT), osteopathy in the cranial field and visceral techniques
  • OMT performed by an osteopath with at least 5 years of pediatric experience.

Results

  • The 1st child received 6 treatments in 70 days: his height increased by 3.5 cm, the ROM from 165 μs to 171 μs, while the weight decreased by 1kg as well as the BMI.
  • The 2nd girl received 6 treatments in 77 days. she grew by 3 cm while both the ROM and the weight remained stable, which resulted in a reduction in BMI.
  • The 3rd child received 3 treatments in 62 days. he showed no changes in height, weight and BMI, while instead the ROM increased from 137°.to 158°. For family problems no other treatments were carried out.
  • The 4th child received 6 treatments in 85 days. The height increased by 3 cm, the weight by 800g, while the BMI remained constant. The ROM also increased slightly from 164° to 167°.
  • The 5th child received 4 treatments in less than 30 days. It grew by 3 cm in height, the weight remained constant, the BMI decreased, while the ROM increased from 150° a 160°. The treatments were interrupted because of the start of the summer holidays.
  • Further analysis: the first OMT session received by each of these children occurred about 5 years after their thoracotomy. Treatments showed no adverse effects. Only once did a reflux episode occur during treatment. This episode was resolved by lifting the child’s head.
    Some restrictions were found mainly near the scars linked to the surgeries, together with a hypomobility of the diaphragm.

Discussion

OMT seemed able to increase the ROM of the right upper limb and the height of the children even if performed years after surgery.

Despite the use of muscle sparing surgery, the literature still reports alterations in ROM that need to be well managed as they can be linked to other negative consequences of the surgery such as scoliosis, chest deformities and scapular elevation.

In the wake of other past studies and reviews showing how OMT can actually have beneficial effects on ROM in the case of thoracotomy, the results obtained in this study encourage more articulate studies in order to verify the effective capacity of OMT on the ROM and the other possible post-surgical negative consequences.

Interesting was also the result on growth, especially in relation to height. As a consequence, children moved to higher percentiles (eg, from the 10th to the 25th percentile) of the population. Literature suggests that 15% of children undergoing surgery tend to grow less. On the other hand, it would have been interesting to also evaluate parameters related to body composition (eg, fat mass and lean mass) as they can help predict nutritional status and various clinical outcomes. Although growth is influenced by many factors, including physiological growth and nutrition, however, the fact that it was the height (and not the weight) to increase in such a short time (even less than 2 months) allows to imply a decisive impact of the OMT on it.

Potentially, the OMT could have favored growth through a modulation of the autonomic nervous system (stimulation of the parasympathetic branch), an induction of tissue healing at the level of post-surgical scars (with reduction of local neuroinflammation) and a decrease in the inflammatory factors present in the blood and lymphatic circulation due to surgery and complications experienced in the following years. Of course, more in-depth studies are needed to confirm these claims, which, if true, should lead to osteopathic interventions at a younger age in order to resolve these dysfunctions at an early stage. These studies must necessarily concern more structural outcomes such as allostatic biomarkers linked to stress levels, autonomic equilibrium, inflammation, quality of life and clinical indicators.

The number of children involved in the study is a limitation as there were only 5 of them, also with different post-operative clinical pictures and age. The lack of a control group also leads to more limitations in the conclusions that can be drawn from the study. Finally, it would have been more accurate to measure the ROM through photos on different planes (frontal and sagittal) and images of the mobility of the skeleton.

The review of Osteopedia

By Marco Chiera

Strengths: the study expands the literature on OMT and esophageal atresia; the possible correlation between OMT and the increase in height is especially interesting, taking into account the short time elapsed from the beginning to the end of the study (on average, children grow 4-7cm per year, that is 0.3-0.6cm per month, so less than what we found here); the OMT was shown to be a safe treatment; the timeline of treatment sessions was useful; accurate discussion of the rational possible underlying effects of OMT; good description of the limitations of the study.

Limits: like all single cases, they are not generalizable. A description of how an adverse effect was taken under consideration is missing.

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