Position statement: osteopathic clinical management for babies, infants, and children

Why is there need for this position statement?

Not all osteopaths clinically manage babies, infants and children, however many do provide clinical support and assistance to them and their caregivers. Osteopaths who do so are responsible for duty of care, reflecting optimum safety, risk management and clinical quality in the best interests of children.

Adverse outcomes in babies, infants and children resulting from manual therapy clinical management approaches are very rare, based over the many decades that records have been maintained on the issue (Hayes and Bezilla 2006; Todd et al 2014). Few babies, infants or children have experienced an adverse outcome in existing research (Humphreys 2010; Driehuis et al 2019).

Osteopathy Australia is unaware of any adverse event complaints involving a registered osteopath for babies, infants or children lodged with either the Australian Health Practitioner Regulation Agency (AHPRA) over the last 10 years or the main professional indemnity insurer (covering 90% of all osteopaths) in the last 10 years.

Babies, infants and children however comprise unique patient populations that do require special consideration when planning clinical care or referral. Many babies, infants and children are unable to provide detailed feedback to inform clinical decision making or the clinical management they receive. Obtaining ‘true’ informed consent can be problematic.

Scientific evidence also points to the immaturity of nervous and vascular systems, as well as joint structures in babies, infants and children (Gatterbauer 2009; Safer Care Victoria 2019). Osteopaths are professionally and individually responsible for applying the highest standard of precaution, including approaches appropriate to age and developmental stage.

This position statement describes clinical cautions that Osteopathy Australia recommends its members incorporate into their clinical practice with babies, infants and children to enhance care and patient safety.

The position has been developed for osteopaths, other health professionals, health consumers and external stakeholders to recognise specific differing clinical risks in these patient populations and uphold safety.

Position scope

While a child is legally defined as any person under 18 years of age in Australia, this position statement concerns babies, infants and children (aged under 12 years).

Osteopathy Australia’s position

Clinical risk is higher in babies, infants, and children. Risk is also influenced by the training, experience and competence of a practitioner. Clinical practice with babies, infants and children requires osteopaths to have current knowledge, skills and ongoing commitment to developing further knowledge of:

• Paediatric assessment and assessment approaches.
• Working with parents, caregivers, babies, infants and children in clinical settings; managing issues of informed consent and patient safety with these patient groups.
• Recognising complex health conditions and their trajectories, with particular reference to paediatric red flags.
• Recognising a child in distress, trauma or need, with particular reference to paediatric yellow flags.
• Child physiology, development and physiological variations within and between babies, infants, children, as well as differences to the maturing body.
• Normal physiological development, including normal range of movement and neurological development, and how to distinguish atypical development.
• Health services, referral pathways and broader supports for parents, caregivers, babies, infants and children; as well as when and how to engage them.
• Contraindications to manual therapy and other management approaches, and current scientific debates/considerations in use of specific modalities in babies, infants and children.
• Appropriate forces for application to growing bodies, irrespective of technique or modality applied.

Osteopathy Australia recommends that spinal manipulative techniques not be used on babies, infants or children aged under 12 years, given limited systematic evidence of clinical benefit for these patient groups. Further considerable public and regulatory concern has been raised in relation to the practice (AMA 2013; AHPRA 2016, Safer Care Victoria 2019).

A range of other clinical management approaches can be used to encourage range of movement, physical mobility and age-appropriate skill growth while managing
potential clinical risk. Where relevant to a differential diagnosis, management options could include soft tissue manual therapy approaches, positional or postural advice, aids, toy or appliance prescription, play activity prescription and/or exercise programming.

Practitioners should reflect on their own level of experience, current knowledge or training and confidence in working with paediatric populations. Where there is any doubt, caution should be exercised and an appropriate referral made. Practitioners need to consider these to uphold their own professional indemnity and regulatory obligations (OBA 2017).

The responsibility falls on the practitioner to explain contraindications to caregivers so that informed health care choices can be made through agreed partnership. Use of any clinical management approach needs to be grounded in clinical evidence, clinical reasoning and aligned with the training and experience of a practitioner.

Practitioners are reminded that inappropriate use of a therapeutic technique can lead to regulatory and legal action, up to an including loss of registration where deemed suitable by the Australian Health Practitioner Regulation Agency (AHPRA).

Osteopathy Australia is committed to supporting members to apply clinical risk management practices to babies, infants and children through clinical guidelines, resources and professional education.

Note: other health practitioners and consumers may see reference to osteopathic manipulative therapy (OMT) in publications, including those on paediatric treatment. It is important to understand that OMT is a general term collectively used to describe many dozens of osteopathic manual therapy techniques, including but not limited to spinal manipulation. In addition to skilled clinical exercise programming, manual therapies are a broad class of therapies offered by osteopaths. An osteopath may talk about OMT and have no intention of using spinal manipulation. If caregivers have any concerns, they should discuss this directly with the osteopath.

Authorisation

This position statement was informed by review of current research and a peer consultative process involving Osteopathy Australia’s titled Advanced Paediatric Osteopaths.

Review

This position statement was first developed in 2016 and updated in 2021. It is to be reviewed in 2026, or as often as required to reflect emerging clinical evidence, practice issues or regulatory requirements.

Related position statements

Osteopathy Australia, ‘Osteopaths, Children and the wider Health Care System’.

Contact

To provide feedback or comment on this position statement, please contact Osteopathy Australia by:

Phone: (02) 9410 00 99 or

email: info@osteopathy.org.au

References

Australian Health Practitioner Regulation Agency (AHPRA), ‘Register of practitioners’ [online] https://www.ahpra.gov.au/Registration/Registers-of-Practitioners.aspx

Australian Medical Association (AMA), ‘AMA concerns with chiropractors treating children’ October 2013 [online] https://www.ama.com.au/media/ama-concerns-chiropractors-treating-children

Driehuis, F., et al, ‘Spinal manual therapy in infants, children and adolescents: A systematic review and meta-analysis on treatment indication, technique and outcomes’, PLoS ONE 14(6); June 2019, pages 1-22

Gatterbauer, A., 2009, Contraindications in Osteopathy, Masters Thesis, Vienna School of Osteopathy, Austria

Hayes, N. & Bezilla, T., ‘Incidence of iatrogenesis associated with osteopathic manipulative treatment of pediatric patients’, Journal of the American Osteopathic Association, volume 106, October 2006, pages 605-608

Humphreys, B., ‘Possible adverse events in children treated by manual therapy: a review’, Chiropractic and Osteopathy, volume 18, issue 12, December 2010, pages 1-7

Safer Care Victoria, ‘Chiropractic Spinal Manipulation of Children Under 12’, Victorian Government review 2019 [online]; https://www.safercare.vic.gov.au/publications/chiropractic-spinal-manipulation-of-children-under-12

Osteopathy Board of Australia (OBA), ‘Statement on Paediatric Care’, March 2017 [online]; https://www.osteopathyboard.gov.au/Codes-Guidelines/Position-statements/Statement-on-paediatric-care.aspx

Todd, A., et al, ‘Adverse events due to chiropractic and other manual therapies for infants and children: a review of the literature’, Journal of Manipulative Physiological Therapeutics, October 2014, pages 1-6