Prevalence, risk factors, and natural history of positional plagiocephaly: a systematic review

Analysis of the correlation between deformational plagiocephaly and neurodevelopmental delay

BACKGROUND

Deformational plagiocephaly (DP) refers to cranial asymmetry resulting from uneven external forces. A strong association exists between DP and developmental delay. We investigated the effect of DP severity on developmental delay.

METHODS

Between 2010 and 2016, data from 155 patients with DP were reviewed retrospectively. Two indices were used to evaluate the deformation quantitatively: cranial index (CI) and cranial vault asymmetry index (CVAI). The Bayley Scales of Infant Development-II was used to evaluate the neurodevelopment of patients.

RESULTS

According to the CI of the study population, 2 patients showed scaphocephaly, 12 showed mesocephaly, and 141 showed brachycephaly. For CVAI, 10 patients showed values of <3.5, 10 patients showed mild deformity (3.5-6.25), 27 patients showed moderate deformity (6.25-8.75), and 108 patients showed severe deformity. The means of the mental development index (MDI) and psychomotor development index (PDI) were 91.69 ± 16.8 and 92.28 ± 17.59, respectively; after the exclusion of patients with confounding factors, the values were 96.26 and 92.9, respectively. The Spearman correlation coefficients between MDI and CI and CVAI were -0.019662 and 0.118916, respectively, whereas for PDI, the values were -0.195428 and -0.012386, respectively.

CONCLUSIONS

There was a statistically significant neurodevelopmental delay in patients with DP. However, accelerated neurodevelopment was also encountered in many patients. MDI was found to be more affected by multiple confounding factors than PDI, whereas PDI was only affected by congenital anomalies. There was no definitive relationship between the severity of DP and the degree of developmental delay in our study group.

Positional Skull Deformities

BACKGROUND

Especially in the first 6 months of life, skull deformities manifesting as a uni- or bilateral flattening of the occiput often give rise to questions of differential diagnosis and potential treatment. In this review, the authors summarize the current understanding of risk factors for this condition, and the current state of the relevant diagnostic assessment and options for treatment.

METHODS

The recommendations given in this selective review of the literature are based on current studies and on existing guidelines on the prevention of sudden infant death, the recommendations of the German Society for Pediatric Neurology (Deutsche Gesellschaft für Neuropädiatrie), and the American guidelines on the treatment of positional plagiocephaly in infancy.

RESULTS

Pre-, peri-, and postnatal risk factors can contribute to the development of positional skull deformities. These deformities can be diagnosed and classified on the basis of their clinical features, supplemented in unclear cases by ultrasonography of the cranial sutures. The putative relationship between positional skull deformities and developmental delay is currently debated. The main preventive and therapeutic measure is parent education to foster correct positioning habits (turning of the infant to the less favored side; prone positioning on occasion when awake) and beneficial stimulation of the infant (to promote lying on the less favored side). If the range of motion of the head is limited, physiotherapy is an effective additional measure. In severe or refractory cases, a skull orthosis (splint) may be useful.

CONCLUSION

The parents of children with positional skull deformities should be comprehensively informed about the necessary preventive and therapeutic measures. Treatment should be initiated early and provided in graded fashion, according to the degree of severity of the problem. Parental concern about the deformity should not be allowed to lead to a rejection of the reasonable recommendation for a supine sleeping position.

Relationship between starting age of cranial-remolding-orthosis therapy and effectiveness of treatment in children with deformational plagiocephaly

PURPOSE

The aim of this study was to investigate the optimal age for starting cranial-remolding-orthosis therapy in children with deformational plagiocephaly.

METHODS

Medical records of 310 patients with deformational plagiocephaly were retrospectively reviewed and the initial and final cranial vault asymmetry index (CVAI), age when starting therapy, duration of therapy, mean change of CVAI, improvement rate, and treatment success were analyzed. We compared outcomes according to the groups divided by ages starting therapy.

RESULTS

There were no significant differences in improvement rate and duration of cranial-remolding-orthosis therapy among patients starting therapy at the age of 3, 4, and 5 months. However, when starting therapy after the age of 6 months, the rates of CVAI improvement were significantly lower and the duration of therapy was significantly increased.

CONCLUSION

Considering the spontaneous resolution effect according to the head growth nature, the age 5 month is the optimal period to start cranial-remolding-orthosis therapy for deformational plagiocephaly.

[Effects of deformational plagiocephaly during the first 12 months on the psychomotor development of prematurely born infants]

AIMS

The link between deformational plagiocephaly and psychomotor development is a recurrent question in medical publications. Main publications concentrate on term infants, but there is a lack of data on the impact of deformational plagiocephaly on the long-term neurodevelopment of premature infants. We attempted to establish a possible relation between deformational plagiocephaly during the 1st year of life and the psychomotor score at 4 years in prematurely born infants. Other risk factors potentially impacting the psychomotor score were also studied.

MATERIAL AND METHODS

A retrospective study of the files of the children followed by the "Naître et Devenir Région PACA Ouest Corse Sud" healthcare network and included in the database allowed us to select a cohort of 594 infants born prematurely at under 33 weeks of gestational age. These children were developmentally evaluated during the 1st year of life and at 4 years or age using the "EVAL Mater" test. The "Naître et Devenir" network is following up infants born prematurely at under 33 weeks of gestation in the West Provence Alpes Côte d'Azur and South Corsica region, from discharge to 7 years. A group of 170 specially trained pediatricians follow these infants developmentally at term, 3, 6, 9, 12, 18, and 24 months of corrected age and 3, 4 5, 6, and 7 years. Data are collected in a specially designed database.

RESULTS

There was no significant link between deformational plagiocephaly during the 1st year of life and a pathological psychomotor score at age 4, but some risk factors were demonstrated: male gender, birth at under 28 weeks of gestational age, weight at birth under 1000g, having a Latal and Ferriero neuromotor score equal to or greater than 2 at 3 months of corrected age, and to a lesser extent having a prescription for physiotherapy during the 1st year.

CONCLUSION

The research on deformational plagiocephaly in the full-term infant suggests a relation between deformational plagiocephaly and developmental delay predominantly on the motor side, with an increased rate of special needs services at school age. The question is raised of whether deformational plagiocephaly is the cause of the delay or an early sign of cerebral anomaly with an early motor delay in full-term infants. The results suggest that deformational plagiocephaly in the prematurely born infant may not be related to neurodevelopmental delay but simply to the extended time spent in the supine position because of the early birth associated with physiological hypotonia and axial extension. Other risk factors such as male gender, birth before 28 weeks of gestation, weight less than 1000g, a Latal and Ferriero neuromotor score greater than 2 at 3 months of corrected age, and having a prescription for physiotherapy during the 1st year of life are strongly related to delayed psychomotor development at age 4.

Deformational plagiocephaly in normal infants: a systematic review of causes and hypotheses

BACKGROUND

Deformational plagiocephaly (DP) is one of the most prevalent abnormal findings in infants and a frequent reason for parents to seek paediatric advice.

OBJECTIVE

To systematically review the literature and identify evidence and hypotheses on the aetiology and determinants of DP in otherwise healthy infants.

DESIGN

Systematic keyword search in all major biomedical databases to identify peer-reviewed publications reporting (a) empirical research or (b) hypotheses on the aetiology of DP in healthy, term infants. 3150 studies published between 1985 and 2016 and containing relevant keywords were screened. In a two-pronged approach, results were summarised separately for the body of empirical work (22 studies) and the body of hypotheses (110 articles).

REVIEW FINDINGS

Only a few empirical studies have examined risk factors in non-selected patient populations on a higher grade methodological level. The most commonly reported risk factors were: male gender, supine sleep position, limited neck rotation or preference in head position, first-born child, lower level of activity and lack of tummy time. Agreement between empirical studies was poor for most exposures, including supine sleep position, tummy time and use of car seats. The articles reporting hypotheses on the aetiology of DP cover a wide field of environmental and biological factors, but include little suggestions as to the potential influence of the everyday care environment of the baby.

CONCLUSIONS AND RELEVANCE

The evidence on the aetiology of DP is fragmentary and heterogeneous. In addition, factors possibly relevant to the development of DP have not been appreciated in the scientific discussion.

Assessing the Cervical Range of Motion in Infants With Positional Plagiocephaly

PURPOSE

To determine if infants with positional plagiocephaly have limitations of active and passive cervical range of motion measured with simple and reliable methods.

METHODS

The examiners assessed bilateral active and passive cervical rotations and passive cervical lateral flexion. Cervical assessment was performed twice by 2 different physicians to assess intertester reliability. To assess intratester reliability the first investigator performed a second examination 48 hours after the first one.

RESULTS

One-hundred nine subjects were analyzed; 70.7% of the sample had head positional preference on the right, while 29.3% had head positional preference on the left (χ 35.52, P <0.001). Cervical rotations and lateral flexion showed reliable levels of agreement for intra and intertester reliability.

CONCLUSIONS

The most limited range of motion in infants with positional plagiocephaly was cervical active rotation which affected more than 90% of patients. Passive cervical rotations and lateral flexion were limited in more than 60% of patients.

Neurological assessment of Chinese infants with positional plagiocephaly using a Chinese version of the Infant Neurological International Battery (INFANIB)

PURPOSE

Positional plagiocephaly (PP) is the most common subtype of asymmetric deformity in the infant skull. Cumulative evidence has demonstrated that PP is associated with abnormal neuromotor development; however, neurological assessment scores of infants with PP have not been well established, and PP has not attracted sufficient attention in China. This study used a Chinese version of the Infant Neurological International Battery (INFANIB) to identify neurological abnormalities among infants with PP and to determine the differences between infants with different (mild, moderate, and severe) degrees of PP.

METHODS

We compared the neurological evaluation scores between 393 infants with different degrees of PP and 390 healthy infants from 0 to 18 months of age using a Chinese version of the INFANIB.

RESULTS

The infants with PP aged 0-7.9 months had lower scores on the spasticity, head and trunk, leg, and French angle subscales and lower total scores than the normal infants. Additionally, the infants with PP aged 9-18 months showed statistically significantly lower scores on the spasticity, head and trunk, vestibular function, leg, and French angle subscales and total scores than the normal infants. Among the PP subgroups, the infants with mild PP had the highest scores, followed by the infants with moderate PP and the infants with severe PP. Compared with the normal infants, the infants with PP had abnormal neurological assessment scores, and the degree of neurological abnormality was associated with the severity of PP.

CONCLUSIONS

The INFANIB revealed neurological abnormalities, including asymmetric movements and abnormal muscle tone, postures, and reflexes, in infants with PP, especially those with moderate or severe PP. These abnormalities were similar to those of infants with cerebral palsy. Therefore, PP may serve as a marker of neurodevelopmental risk and should receive considerable attention. Whether moderate or severe PP is related to cerebral palsy remains to be confirmed in long-term follow-up studies and other future studies.

The course of skull deformation from birth to 5 years of age: a prospective cohort study

In a continuation of a prospective longitudinal cohort study in a healthy population on the course of skull shape from birth to 24 months, at 5 years of age, 248 children participated in a follow-up assessment using plagiocephalometry (ODDI-oblique diameter difference index, CPI-cranio proportional index). Data from the original study sampled at birth, 7 weeks, 6, 12, and 24 months were used in two linear mixed models.

MAIN FINDINGS

(1) if deformational plagiocephaly (ODDI <104%) and/or positional preference at 7 weeks of age are absent, normal skull shape can be predicted at 5 years of age; (2) if positional preference occurs, ODDI is the highest at 7 weeks and decreases to a stable lowest value at 2 and 5 years of age; and (3) regarding brachycephaly, all children showed the highest CPI at 6 months of age with a gradual decrease over time.

CONCLUSION

The course of skull deformation is favourable in most of the children in The Netherlands; at 5 years of age, brachycephaly is within the normal range for all children, whereas the severity of plagiocephaly is within the normal range in 80%, within the mild range in 19%, and within the moderate/severe range in 1%. Medical consumption may be reduced by providing early tailored counselling. What is Known: • Skull deformation prevalence increased after recommendations against Sudden Infant Death Syndrome, little is known about the longitudinal course. • Paediatric physical therapy intervention between 2 and 6 months of age reduces deformational plagiocephaly at 6 and 12 months of age. What is New: • The course of skull deformation is favourable in most of the children in The Netherlands; at 5 years of age, deformational brachycephaly is within the normal range for all children, whereas the severity of deformational plagiocephaly is within the normal range in 80%, within the mild range in 19%, and within the moderate to severe range in only 1%. • Paediatric physical therapy intervention does not influence the long-term outcome; it only influences the earlier decrease of the severity of deformational plagiocephaly.

Plagiocephaly and Developmental Delay: A Systematic Review

OBJECTIVE

Deformational plagiocephaly (includes plagiocephaly and brachycephaly) is a common pediatric condition. Infants who present with altered head shape often experience developmental delay. It is uncertain how common developmental delay is in infants with plagiocephaly and how sustained this is, when present. This review explores the association between plagiocephaly and developmental delay to guide clinical practice.

STUDY DESIGN

A systematic review was conducted. MEDLINE, EMBASE, CINAHL, and PEDro databases were searched. Data from relevant studies were extracted regarding study: sample, follow-up, design, and findings. Methodological quality of each study was rated using a critical appraisal tool.

RESULTS

The search recovered 1315 articles of which 19 met the inclusion criteria. In the included studies, the children's ages ranged from 3 months to 10 years. Study limitations included selection bias, nonblinding of assessors, and reuse of the same study population for multiple papers. Most papers (11/19) rated "moderate" on methodological quality. A positive association between plagiocephaly and developmental delay was reported in 13 of 19 studies, including 4 of 5 studies with "strong" methodological quality. Delay was more frequently in studies with children ≤24 months of age (9/12 studies) compared with >24 months of age (3/7 studies). Motor delay was the most commonly affected domain reported in high-quality papers (5/5 studies).

CONCLUSION

This review suggests plagiocephaly is a marker of elevated risk of developmental delays. Clinicians should closely monitor infants with plagiocephaly for this. Prompt referral to early intervention services such as physiotherapy may ameliorate motor delays and identify infants with longer term developmental needs.

The course of positional cranial deformation from 3 to 12 months of age and associated risk factors: a follow-up with 3D imaging

Deformational plagiocephaly is reported in up to 46.6 % of healthy infants, with the highest point prevalence at around 3 months of age. Few prospective studies on the natural course of skull deformation have been conducted, and we know of no studies using 3D imaging starting from the highest point prevalence period. In this prospective, population-based cohort study, we describe the course of cranial asymmetry and shape in an unselected population using 3D stereophotogrammetry and investigate factors associated with late cranial deformation and failure to recover from previous deformation. We evaluated 99 infants at 3, 6, and 12 months of age. We acquired 3D craniofacial images and performed structured clinical examinations and parental interviews at each visit. Eight outcome variables, representing different aspects of cranial shape, were calculated from a total of 288 3D images. Scores of asymmetry-related variables improved throughout the observation period. However, the rate of correction for cranial asymmetry decreased as the infants grew older, also in relation to the rate of head growth, and a significant amount of asymmetry was still present at 12 months. Positional preference at 3 months predicted an unfavorable course of cranial asymmetry after 3 months, increasing the risk for DP persisting. What is known: • The prevalence of deformational plagiocephaly spontaneously decreases after the first months of life. • Limited neck range of motion and infant positional preference increase the risk of deformational plagiocephaly during the first months of life. What is new: • Positional preference at 3 months predicts an unfavorable spontaneous course of deformation also from three to 12 months of age, presenting a potential target for screening and treatment. • The spontaneous rate of correction for cranial asymmetry decreases after 6 months of age, also in relation to the rate of head growth.

Effects of manual therapy on treatment duration and motor development in infants with severe nonsynostotic plagiocephaly: a randomised controlled pilot study

PURPOSE

Despite growing evidence regarding nonsynostotic plagiocephaly and their repercussions on motor development, there is little evidence to support the use of manual therapy as an adjuvant option. The aim of this study was to evaluate the effects of a therapeutic approach based on manual therapy as an adjuvant option on treatment duration and motor development in infants with severe nonsynostotic plagiocephaly.

METHODS

This is a randomised controlled pilot study. The study was conducted at a university hospital. Forty-six infants with severe nonsynostotic plagiocephaly (types 4-5 of the Argenta scale) referred to the Early Care and Monitoring Unit were randomly allocated to a control group receiving standard treatment (repositioning and an orthotic helmet) or to an experimental group treated with manual therapy added to standard treatment. Infants were discharged when the correction of the asymmetry was optimal taken into account the previous clinical characteristics. The outcome measures were treatment duration and motor development assessed with the Alberta Infant Motor Scale (AIMS) at baseline and at discharge.

RESULTS

Asymmetry after the treatment was minimal (type 0 or 1 according to the Argenta scale) in both groups. A comparative analysis showed that treatment duration was significantly shorter (p < 0.001) in the experimental group (109.84 ± 14.45 days) compared to the control group (148.65 ± 11.53 days). The motor behaviour was normal (scores above the 16th percentile of the AIMS) in all the infants after the treatment.

CONCLUSIONS

Manual therapy added to standard treatment reduces the treatment duration in infants with severe nonsynostotic plagiocephaly.

Orthotic Management of Deformational Plagiocephaly: Consensus Clinical Standards of Care

Objective

To establish consensus on definitive, actionable standards for the management of deformational plagiocephaly.

Design

Three-stage Delphi Survey process based on best practice statements obtained through literature review.

Setting

Electronic survey delivery.

Participants

Review panel of 10 multidisciplinary subject matter experts (SMEs); survey panel of 30 cranial orthotists.

Results

Fifty-four best practice statements were accepted in four categories: diagnosis, presentation and severity, initiating treatment, and management principles.

Conclusions

Clinical practice can be guided en route to robust evidence as to the efficacy of various plagiocephaly management strategies, in pursuit of definitive standards.

Clinical assessment of head orientation profile development and its relationship with positional plagiocephaly in healthy term infants - A prospective study

BACKGROUND

Positional plagiocephaly refers to atypical development of an uneven head shape with asymmetrical head orientation as a post-natal risk factor. The development of the head orientation profile and its relationship with positional plagiocephaly are lacking.

OBJECTIVES

To explore the head orientation profile development and its relationship with positional plagiocephaly in healthy full term infants.

METHODS

A prospective observational study including 94 infants was conducted. Head orientation measures including head orientation duration, head orientation strength and latency to turn were conducted at three, six and nine weeks of age. Plagiocephaly outcome was measured by modified Cranial Vault Asymmetry Index at nine weeks.

RESULTS

Lateral head orientation duration predominated at three weeks, mean (standard deviation) (right=40 [21.7]%; left=41 [21.5]%; midline=19 [19.9]%). It decreased bilaterally in favour of midline positioning at nine weeks (right=30 [22.3]%; left=24 [22.0]%; midline=46 [27]%. Although head orientation strength was similar across the three ages after accounting for side, head orientation strength to left was decreased from three to nine weeks (p=0.031; 95% CI: 0.12-2.06). There was a reduction in left-consistent with increase in left-bias from 3weeks to 6weeks of age (p=0.011). Positional plagiocephaly at nine weeks was associated with head orientation duration-right (p<0.001; r(2)=0.20); head orientation duration-left (p<0.001; r(2)=0.17); head orientation strength at three and six weeks (p<0.001; r(2)=0.22), but not latency to turn.

CONCLUSIONS

Healthy infants show progressive change from symmetrical lateral head orientation to midline orientation from three to nine weeks. There is association of head orientation duration and strength with positional plagiocephaly.

Insufficient vitamin D supplement use during pregnancy and early childhood: a risk factor for positional skull deformation

Vitamin D insufficiency during pregnancy is associated with disturbed skeletal homeostasis during infancy. Our aim was to investigate the influence of adherence to recommendations for vitamin D supplement intake of 10 μg per day (400 IU) during pregnancy (mother) and in the first months of life (child) on the occurrence of positional skull deformation of the child at the age of 2 to 4 months. In an observational case-control study, two hundred seventy-five 2- to 4-month-old cases with positional skull deformation were compared with 548 matched controls. A questionnaire was used to gather information on background characteristics and vitamin D intake (food, time spent outdoors and supplements). In a multiple variable logistic regression analysis, insufficient vitamin D supplement intake of women during the last trimester of pregnancy [adjusted odds ratio (aOR) 1.86, 95% (CI) 1.27-2.70] and of children during early infancy (aOR 7.15, 95% CI 3.77-13.54) were independently associated with an increased risk of skull deformation during infancy. These associations were evident after adjustment for the associations with skull deformation that were present with younger maternal age and lower maternal education, shorter pregnancy duration, assisted vaginal delivery, male gender and milk formula consumption after birth. Our findings suggest that non-adherence to recommendations for vitamin D supplement use by pregnant women and infants are associated with a higher risk of positional skull deformation in infants at 2 to 4 months of age. Our study provides an early infant life example of the importance of adequate vitamin D intake during pregnancy and infancy.

Argenta clinical classification of deformational plagiocephaly

INTRODUCTION

A stratification system is useful in deformational plagiocephaly (DP) to help categorize patients and reproduce a consistent treatment strategy. The Argenta classification is a clinical 5-point scale for unilateral DP and 3-point scale for central DP (CDP).

METHODS

A retrospective review was completed for patients with DP and classified using the Argenta clinical classification by plastic surgeons at a tertiary medical center over a 12-year period.

RESULTS

In the 4483 patients, type III was the most prevalent DP type (42%) followed by II, IV, I, and V. Within CDP, VIB was the most common (6%) followed by VIA and VIC. Right-sided DP (56.8%) was more common than left-sided (28.3%) and bilateral (20.4%) (P < 0.0001). For treatment, 89.8% used molding helmet therapy, 9.3% used positioning only, and 0.4% used sock hat. Helmet use increased with increasing type to 98% with type V. In CDP, there was a significant increase in helmet use between VIA and VIB, but helmet use decreased in VIC. There was a higher rate of positioning only in types I, II, and VIA, which diminished as severity increased. Deformational plagiocephaly corrected to type I or 0 in 83.5% of the patients with the highest correction rate in type I (90.7%). Mean age of correction was 11.4 months and time to correction was 5.7 months. Both significantly increased with severity of type in the patients with DP but not in those with CDP.

CONCLUSIONS

The Argenta classification scale allows reliable evaluation for cranial deformities and may help predict the optimal type duration of treatment.

Prevalence and Consequences of Positional Plagiocephaly and Brachycephaly

The incidence of positional plagiocephaly and brachycephaly in infants has increased. Treatment options include physiotherapy and helmet therapy.No information exists on the prevalence, cosmetic, and psychological consequences of plagiocephaly and brachycephaly later in life. This study was performed to assess the prevalence and cosmetic relevance of plagiocephaly and brachycephaly, as well as its influence on quality of life in adolescence.The authors performed plagiocephalomety to assess cranial shape and used a questionnaire that included question about educational level, medical history, cosmetic appearance, and cranial shape. To evaluate quality of life, the authors used the KIDSCREEN-27 questionnaire.All data were analyzed using SPSS version 19.0 2010. The authors included 87 adolescents. The prevalence of plagiocephaly, defined as an oblique diameter difference index (ODDI) higher than 106%, was 10.3%; the prevalence of brachycephaly, defined as a cranial proportional index (CPI) higher than 95%, was 0%.There was no significant correlation between the level of the ODDI or CPI and the cosmetic assessment of cranial shape (P = 0.128/0.541). There was no significant correlation with the level of the ODDI (P = 0.428).There was no significant correlation between the level of the ODDI or CPI and the average T-value for quality of life using the KIDSCREEN quality-of-life questionnaire (P = 0.461/0.713). The prevalence of positional deformities in our population of adolescents, born after the "back to sleep" campaign, is low. There was no significant correlation between the presence of a cranial deformity and the cosmetic judgement and quality of life.

Preventing deformational plagiocephaly through parent guidance: a randomized, controlled trial

Deformational plagiocephaly (DP) occurs frequently in otherwise healthy infants. Many infants with DP undergo physiotherapy or helmet therapy, and ample treatment-related research is available. However, the possibility of preventing DP has been left with little attention. We sought to evaluate the effectiveness of intervention in the newborn's environment, positioning, and handling on the prevalence of DP at 3 months and to investigate the causal relationship between DP and cervical imbalance. We carried out a randomized controlled trial, with healthy newborns randomized into two groups at birth. All families received standard positioning instructions to prevent SIDS. Additionally, the intervention group received detailed instructions regarding the infant's environment, positioning, and handling, with the goal of creating a nonrestrictive environment that promotes spontaneous physical movement and symmetrical motor development. Two- and three-dimensional photogrammetry served to assess cranial shape and goniometry to measure cervical motion. At 3 months, the prevalence of DP was lower in the intervention group in both 2D (11 vs 31 %) and 3D analyses (15 vs 33 %), and the asymmetry was milder in the intervention group. Infants with DP at follow-up had also developed more torticollis.

CONCLUSION

An early educational intervention reduces the prevalence and severity of DP at 3 months.

WHAT IS KNOWN

•Deformational plagiocephaly, often with associated torticollis, is common in healthy infants. •Parental education is frequently recommended for preventing deformational plagiocephaly, although information regarding the effectiveness of preventive strategies is scarce.

WHAT IS NEW

•Early parent guidance effectively reduces the prevalence and severity of DP and improves the cervical range of motion at three months. •Educating both parents and professionals about proper infant positioning on a national scale could help minimize public healthcare costs.

Long-term satisfaction and parental decision making about treatment of deformational plagiocephaly

The incidence of deformational plagiocephaly (DP) has increased greatly during the last 2 decades since the recommendation of supine sleeping. Currently, there are 2 treatment options for DP, helmet therapy and repositioning therapy. This research investigated factors that influenced parental decision making about treatment choice and long-term satisfaction with head shape. A retrospective chart review identified 1660 children, now aged 2 to 10 years, seen in the DP clinic meeting inclusion criteria. Questionnaires were mailed to all eligible families. Four-hundred fifty-six completed questionnaires were returned. The questionnaires evaluated demographics of the family, factors that influenced treatment choice, and satisfaction with current head shape. Most of the respondents had white (93%) and male (70%) children. The mothers' mean age at the time of childbirth was 31 years; most of the mothers had a college degree or higher (77%) and household incomes of more than $76,000 (52.6%). Fifteen factors were used to evaluate which ones were significant in influencing parental treatment choice. Severity of the DP and time off work for follow-up appointments were the only 2 factors identified that significantly affected treatment choice. More parents who used helmet therapy reported that they were satisfied with their child's long-term head shape and would choose the same treatment again (P = 0.002) compared with those who used repositioning therapy.

Can nurses be key players in assessing early motor development using a structured method in the child health setting?

RATIONAL, AIMS AND OBJECTIVES

Increasing evidence highlights the importance of early interventions for motor disorders in children. Given the key medical role of the nurse within the Swedish Child Health Service (CHS), we aimed to examine if nurses could apply a structured assessment of early motor development at the child health centre to enable early identification of children at risk.

METHODS

Structured Observation of Motor Performance in Infants (SOMP-I) assesses infant's level of motor development and quality of motor performance using subscales converted to total scores. The total score for both level and quality can then be plotted within the SOMP-I percentile distribution at the child's age for comparison with a reference population. Fifty-five infants (girls: 30) were assessed according to SOMP-I at three child health centres. Assessments were performed by nurses (n = 10) in a clinical setting; one nurse performed the assessment while another nurse and a physiotherapist observed.

RESULTS

Agreement for the assessment of level as a continuous variable was excellent [intraclass correlation coefficient (ICC) 0.97-0.98], but was lower for quality (ICC 0.02-0.46). When the children were categorized according to the percentile range categories, the assessors were in agreement for the majority of the children, with respect to both level (78-82%) and quality (78-87%).

CONCLUSION

Despite brief experience with SOMP-I, the agreement was excellent when assessing the level of motor development, but was less satisfactory for the assessment of quality of motor performance. More extensive education and training may be necessary to improve the nurses' ability to assess quality, as this domain was an entirely new concept to the nurses. Further research is warranted to determine the applicability of SOMP-I as a standardized method for nurses to assess motor development within the CHS.

Updated Swedish advice on reducing the risk of sudden infant death syndrome

This article reviews updated advice and factual material from the Swedish National Board of Health and Welfare on reducing the risk of sudden infant death syndrome. Issues covered by the guidance for parents and healthcare professionals include sleeping positions, smoking, breastfeeding, bed sharing and using pacifiers.

Conclusion

The guidelines conclude that infants under three months of age are safest sleeping in their own cot and that a pacifier can be used when they are going to sleep.

Positional cranial deformity--the parents' point of view

The parents' point of view regarding positional cranial deformities and helmet therapy has not been the subject of scientific interest yet. However, carer acceptance is a key factor for therapeutic success. We therefore investigated parental perception. The parents of 218 infants were included in a telephone survey; 122 children had undergone helmet therapy and 96 had not. Satisfaction with the outcome, treatment-associated problems, and parental stress were investigated using a structured questionnaire. The great majority (90.8%) of caregivers were satisfied with the outcome, regardless of whether or not helmet therapy was used. Retrospectively, 76% of the parents of infants who had not undergone helmet therapy would decide against helmet therapy again. Therapy was either temporarily stopped (27.0%) or terminated (4.9%) in 31.9% of infants treated with a helmet. Major problems were sweating (51.1%) and skin lacerations (30.9%). The parents indicated minor (54.9%) or even great (25.4%) personal strain. Conflict with others (38.5%), stress for the child (30.3%), and a financial burden (36.9%) were mentioned most frequently. There appear to be more parental problems than expected associated with helmet therapy. Medical experts should take this into consideration. The indication for a helmet should be evaluated critically and the potential parental burdens should be addressed during counselling.

Nonsynostotic Cranial Deformity: A Six-Month Matched-Pair Photogrammetric Comparison of Treated and Untreated Infants

Objective

To photogrammetrically objectify changes in nonsynostotic craniofacial deformity in orthotically treated versus untreated infants.

Design

A statistical retrospective pairwise comparison of two respective three-dimensional (3D) photo scans of 80 children performed in a 6-month time lag.

Patients

Two comparable samples of children (40 treated, 40 untreated) with nonsynostotic cranial deformity.

Interventions

Respective 3D photo scans were matched using Cranioform Analytics 4.0 software.

Main Outcome Measures

Median change of 30° Cranial Vault Asymmetry Index (CVAI), modified CVAI (CVAImod), Cranial Index (CI), and posterior symmetry ratio (PSR).

Results

We found an improvement in Δ30° CVAI by 3.3% (treated) and by 1.31% (untreated), respectively. CVAImod improved by 3.46% in the treated group and by 1.55% in the untreated group. CI improved by 4.41% in the treated group and by 3.68% in the untreated group, and PSR improved by 0.71 in the treated group and 0.49 in the untreated group. Although improvement of cranial asymmetry was higher in those children treated with an individual molding orthosis, we could not document a statistically significant difference between the two groups.

Conclusions

Helmet therapy may be less appropriate for the correction of brachycephaly than for cranial asymmetry. Nonsynostotic cranial deformity shows some spontaneous correction. Photogrammetry presents an accurate method to objectify craniofacial changes in early infancy.

Craniosynostosis of the lambdoid suture

Craniosynostosis affecting the lambdoid suture is uncommon. The definition of lambdoid craniosynostosis solely applies to those cases demonstrating true suture obliteration, similar to other forms of craniosynostosis. In patients presenting with posterior plagiocephaly, true lambdoid craniosynostosis must be differentiated from the much more common positional molding. It can occur in a unilateral form, a bilateral form, or as part of a complex craniosynostosis. In children with craniofacial syndromes, synostosis of the lambdoid suture most often is seen within the context of a pansynostotic picture. Chiari malformations are commonly seen in multisutural and syndromic types of craniosynostosis that affect the lambdoid sutures. Posterior cranial vault remodeling is recommended to provide adequate intracranial volume to allow for brain growth and to normalize the skull shape. Although many techniques have been described for the correction of lambdoid synostosis, optimal outcomes may result from those techniques based on the concept of occipital advancement.

Response to pediatric physical therapy in infants with positional preference and skull deformation

BACKGROUND

Pediatric physical therapy seems to reduce skull deformation in infants with positional preference. However, not all infants show improvement.

OBJECTIVE

The study objective was to determine which infant and parent characteristics were related to responses to pediatric physical therapy in infants who were 2 to 4 months old and had positional preference, skull deformation, or both.

DESIGN

This was a prospective cohort study.

METHODS

Infants who were 2 to 4 months old and had positional preference, skull deformation, or both were recruited by pediatric physical therapists at the start of pediatric physical therapy. The primary outcome was a good response or a poor response (moderate or severe skull deformation) at 4.5 to 6.5 months of age. Potential predictors for responses to pediatric physical therapy were assessed at baseline with questionnaires, plagiocephalometry, and the Alberta Infant Motor Scale. Univariate and multiple logistic regression analyses with a stepwise backward elimination method were performed.

RESULTS

A total of 657 infants participated in the study. At follow-up, 364 infants (55.4%) showed a good response to therapy, and 293 infants (44.6%) showed a poor response. Multiple logistic regression analysis resulted in the identification of several significant predictors for a poor response to pediatric physical therapy at baseline: starting therapy after 3 months of age (adjusted odds ratio [aOR]=1.50, 95% confidence interval [95% CI]=1.04-2.17), skull deformation (plagiocephaly [aOR=2.64, 95% CI=1.67-4.17] or brachycephaly [aOR=3.07, 95% CI=2.09-4.52]), and a low parental satisfaction score (aOR=2.64, 95% CI=1.67-4.17). A low parental satisfaction score indicates low parental satisfaction with the infant's head shape.

LIMITATIONS

Information about pediatric physical therapy was collected retrospectively and included general therapy characteristics. Because data were collected retrospectively, no adjustment in therapy for individual participants could be made.

CONCLUSIONS

Several predictors for responses to pediatric physical therapy in infants who were 2 to 4 months old and had positional preference, skull deformation, or both were identified. Health care professionals can use these predictors in daily practice to provide infants with more individualized therapy, resulting in a better chance for a good outcome.

Cranial shape, size and cervical motion in normal newborns

BACKGROUND

Deformational plagiocephaly (DP) and torticollis are commonly seen in infants and they often co-occur, but little is known of the prevalence and relationship of these conditions in the immediate newborn period. No previous studies focusing on the relationship between cranial shape and cervical motion in newborns can be found.

OBJECTIVES

Determining the incidence rates and characteristics of DP and torticollis and examining the relationship between cervical range of motion (ROM), cranial size and cranial shape in neonates.

METHODS

A single-center, descriptive cross-sectional study including 155 healthy neonates was conducted. Participants were examined during their birth hospitalization. Oblique Cranial Length Ratio (OCLR) and Cephalic Index (CI), indicating cranial asymmetry and shape, were measured from standardized digital photographs with a computer-based cephalometric method. Cervical ROM was measured with goniometry.

RESULTS

7.7% of the newborns had DP and 3.9% had torticollis. 46.4% presented lesser cervical imbalances. DP was associated with gestational diabetes (adjusted OR 5.6; p<0.01) and vacuum assisted delivery (adjusted OR 6.8; p<0.01), but not at all with torticollis. CI correlated strongly with cervical ROM in all directions, while no definite association between cranial asymmetry and cervical motion could be found.

CONCLUSIONS

DP and torticollis are common and minor cervical imbalances very common in normal newborns. Our results support the theory that in most cases neither DP nor torticollis is congenital, but rather develops and worsens synergistically in early infancy. Still, although no direct association between DP and torticollis was found, cranial shape is linked to cervical motion at birth.

Parents' decision for helmet therapy in infants with skull deformation

PURPOSE

Helmet therapy is regularly prescribed in infants with positional skull deformation. Evidence on the effectiveness is lacking, which complicates decision making. This study aims to assess the relation between parents' decision for treatment of skull deformation in their infant and their level of anxiety, decisional conflict, expectations of treatment effect, perceived severity of deformation and perceived side effects.

METHODS

Parents of 5-month-old infants with skull deformation were invited to participate in a survey. Data collection included background characteristics, anthropometric assessment, parent-reported outcomes, decision for treatment (helmet therapy or awaiting natural course), decisional conflict scale and questions about perceived (side) effects of helmet therapy. Factors significantly correlated with treatment decision (p < 0.1) were tested in a multiple logistic regression analysis.

RESULTS

The results of 186 respondents were included in the analysis. Parental satisfaction with their infant's head shape (adjusted odds ratio (aOR) 0.2; 95 % confidence interval (CI) 0.1 to 0.4), expected effect of helmet therapy compared to natural course (aOR 13.4; 95 % CI 5.0 to 36.1) and decision uncertainty (aOR 1.0; 95 % CI 0.9 to 1.0; p = .03) were related to the decision for helmet therapy in infants with skull deformation.

CONCLUSION

With the outcomes of this study, we can better understand parental decision-making for elective 'normalizing' treatments in children, such as helmet therapy in infants with skull deformation. Health care professionals should address the parents' perception of the severity of skull deformation and their expectations of helmet therapy. Furthermore, they can support parents in decision-making by balancing medical information with parents' expectations, values and beliefs.

A continuous point measure for quantifying skull deformation in medical diagnostics

Deformational plagiocephaly (DP) manifests in a deformed skull primarily caused by retaining a constant sleeping position in infants. Manual measures of skull asymmetry based on MRI or CT scans combined with the cranial vault asymmetry index (CVAI) provides information on the extent of asymmetry. CVAI uses four points on the skull as markers for the asymmetry index but tends to underestimate the deformity because of the lack of sampling points. Computer-based continuous-point methods may be a more objective measure with better sensitivity for the skull contour. The outline of the skull circumference of infants with confirmed cranial deformity was obtained from the literature and analysed applying the mean bending energy (MBE) obtained from the Hermitian wavelet. MBE was shown to correlate with CVAI in the current sample and has the potential to add both quantitative and visual information in 2D or 3D space for the clinician to diagnose DP. Wavelet-based continuous-point estimation of skull asymmetry is a useful method as it is more sensitive to mild deformation anywhere along the skull outline and in assessing slow but progressive improvement as a result of treatment. The broader significance is that this method can be applied to other structural pathology analysis in clinical practice.

Positional plagiocephaly: an analysis of the literature on the effectiveness of current guidelines

OBJECT

Positional plagiocephaly (PP) has been on the rise in recent years. In this review, the authors' aim was to assess the effectiveness of current recommendations to parents on this exceedingly common problem through a comprehensive literature search. Additionally, the current treatment options and the most recent studies on PP are reviewed.

METHODS

A search of the existing literature was conducted to obtain all relevant studies on guidelines, recommendations, parental and clinician practices, and epidemiological aspects.

RESULTS

Although the incidence and risk factors for PP have been well delineated, there continues to be debates on its management and association with developmental delays. Current guidelines and recommendations on prevention set by the American Association of Pediatrics may not be easily followed by both parents and clinicians. There is also evidence that certain populations, including those with lower education, socioeconomic status, and in particular geographic regions may be more affected by the condition. Additionally, the marketing and financial aspects of PP treatments exist and should be addressed.

CONCLUSIONS

Better awareness and education are necessary to inform the population as a whole, although certain populations should be given special attention. Additionally, current guidelines and recommendations can be modified to foster a better grasp of the condition by both parents and clinicians. Adjusting current recommendations, introducing initiatives, and offering elaborate educational campaigns would help deliver these aims. Educating parents on PP as early as possible through clearer guidelines and close monitoring is central to preventing and managing this common condition.

Three-dimensional head shape quantification for infants with and without deformational plagiocephaly

OBJECTIVE

The authors developed and tested three-dimensional (3D) indices for quantifying the severity of deformational plagiocephaly (DP).

DESIGN

The authors evaluated the extent to which infants with and without DP (as determined by clinic referral and two experts' ratings) could be correctly classified.

PARTICIPANTS

Infants aged 4 to 11 months, including 154 with diagnosed DP and 100 infants without a history of DP or other craniofacial condition. After excluding participants with discrepant expert ratings, data from 90 infants with DP and 50 infants without DP were retained.

MEASUREMENTS

Two-dimensional (2D) histograms of surface normal vector angles were extracted from 3D mesh data and used to compute the severity scores.

OUTCOME MEASURES

Left posterior flattening score (LPFS), right posterior flattening score (RPFS), asymmetry score (AS), absolute asymmetry score (AAS), and an approximation of a previously described 2D measure, the oblique cranial length ratio (aOCLR). Two-dimensional histograms localized the posterior flatness for each participant.

ANALYSIS

The authors fit receiver operating characteristic curves and calculated the area under the curves (AUC) to evaluate the relative accuracy of DP classification using the above measures.

RESULTS

The AUC statistics were AAS = 91%, LPFS = 97%, RPFS = 91%, AS = 99%, and aOCLR = 79%.

CONCLUSION

Novel 3D-based plagiocephaly posterior severity scores provided better sensitivity and specificity in the discrimination of plagiocephalic and typical head shapes than the 2D measurements provided by a close approximation of OCLR. These indices will allow for more precise quantification of the DP phenotype in future studies on the prevalence of this condition, which may lead to improved clinical care.

Comparison of helmet therapy and counter positioning for deformational plagiocephaly

OBJECTIVE

To compare effectiveness on correcting cranial and ear asymmetry between helmet therapy and counter positioning for deformational plagiocephaly (DP).

METHODS

Retrospective data of children diagnosed with DP who visited our clinic from November 2010 to October 2012 were reviewed. Subjects ≤10 months of age who showed ≥10 mm of diagonal difference were included for analysis. For DP treatment, information on both helmet therapy and counter positioning was given and either of the two was chosen by each family. Head circumference, cranial asymmetry measurements including diagonal difference, cranial vault asymmetry index, radial symmetry index, and ear shift were obtained by 3-dimensional head-surface laser scan at the time of initiation and termination of therapy.

RESULTS

Twenty-seven subjects were included: 21 had helmet therapy and 6 underwent counter positioning. There was no significant difference of baseline characteristics, head circumferences and cranial asymmetry measurements at the initiation of therapy. The mean duration of therapy was 4.30±1.27 months in the helmet therapy group and 4.08±0.95 months in the counter positioning group (p=0.770). While cranial asymmetry measurements improved in both groups, significantly more improvement was observed with helmet therapy. There was no significant difference of the head circumference growth between the two groups at the end of therapy.

CONCLUSION

Helmet therapy resulted in more favorable outcomes in correcting cranial and ear asymmetry than counter positioning on moderate to severe DP without compromising head growth.

Long-term neurodevelopmental follow-up of children with congenital muscular torticollis

Congenital muscular torticollis is a common condition, but long-term neurodevelopmental follow-up is lacking. This study reports on neurodevelopmental outcome of 68 children, aged 7 to 9 years, with a history of congenital muscular torticollis, excluding children with torticollis due to other conditions. Thirty-eight children were examined for presence of neurodevelopmental disorders. Telephone interview data were available for an additional 30 children. Of those examined, 22/38 (57.9%) had or were at risk for a developmental disorder (attention-deficit hyperactivity disorder (ADHD), developmental coordination disorder, language impairment, autistic spectrum disorder) on at least 1 of the assessments administered, 23/38 (60.5%) had received developmental treatment during childhood. One child, based on a telephone interview, had a history of developmental treatment. Therefore, 30/68 (44.1%) children of the total sample demonstrated a developmental delay/disorder, currently (22/68) or previously (8/68). Our findings suggest congenital muscular torticollis to be a significant risk factor for later neurodevelopmental conditions with disorders presenting at different stages of development.

Clinical course of asymmetric motor performance and deformational plagiocephaly in very preterm infants

OBJECTIVES

To describe the clinical courses of positional preference and deformational plagiocephaly up to 6 months corrected age (CA) in infants born at gestational age <30 weeks or birth weight <1000 g, and to explore predictive factors for the persistence of these phenomena.

STUDY DESIGN

A total of 120 infants were examined 3 times each. The presence of deformational plagiocephaly and a score of 0-6 on an asymmetry performance scale served as outcome measures at 6 months CA. Predictive factors were determined using regression analysis.

RESULTS

The prevalence of a positional preference of the head was 65.8% (79 of 120) at term-equivalent age (TEA) and 36.7% (44 of 120) at 3 months CA and that of deformational plagiocephaly was 30% (36 of 120) at TEA and 50% (60 of 120) at 3 months CA. At 6 months CA, 15.8% of the infants (19 of 120) scored ≥ 2 of a possible 6 on the asymmetry performance scale and 23.3% (28 of 120) had deformational plagiocephaly. Sleeping in the supine position was predictive of an asymmetric motor performance at 6 months CA. Chronic lung disease and/or slow gross motor maturation at 3 months CA predicted the persistence of deformational plagiocephaly.

CONCLUSION

Infants born very preterm may develop deformational plagiocephaly. A positional preference of the head at TEA seems to be a normal aspect of these infants' motor repertoire, with limited ability to predict persistence of an asymmetric motor performance. The decreased prevalence of deformational plagiocephaly between 3 and 6 months CA indicates an optimistic course. Infants with a history of chronic lung disease and/or slow gross motor maturation merit timely intervention.

The incidence of positional plagiocephaly: a cohort study

OBJECTIVE

The objective of this study was to estimate the incidence of positional plagiocephaly in infants 7 to 12 weeks of age who attend the 2-month well-child clinic in Calgary, Alberta, Canada.

METHODS

A prospective cohort design was used to recruit 440 healthy full-term infants (born at ≥37 weeks of gestation) who presented at 2-month well-child clinics for public health nursing services (eg, immunization) in the city of Calgary, Alberta. The study was completed in 4 community health centers (CHCs) from July to September 2010. The CHCs were selected based on their location, each CHC representing 1 quadrant of the city. Argenta's (2004) plagiocephaly assessment tool was used to identify the presence or absence of plagiocephaly.

RESULTS

Of the 440 infants assessed, 205 were observed to have some form of plagiocephaly. The incidence of plagiocephaly in infants at 7 to 12 weeks of age was estimated to be 46.6%. Of all infants with plagiocephaly, 63.2% were affected on the right side and 78.3% had a mild form.

CONCLUSIONS

To our knowledge, this is the first population-based study to investigate the incidence of positional plagiocephaly using 4 community-based data collection sites. Future studies are required to corroborate the findings of our study. Research is required to assess the incidence of plagiocephaly using Argenta's plagiocephaly assessment tool across more CHCs and to assess prevalence at different infant age groups. The utility of using Argenta's plagiocephaly assessment tool by public health nurses and/or family physicians needs to be established.

A prospective randomized trial on preventative methods for positional head deformity: physiotherapy versus a positioning pillow

OBJECTIVE

To evaluate the impact of stretching exercises versus available bedding pillows on positional head deformities.

STUDY DESIGN

Fifty children aged 5 months or younger with positional head deformity were included in this prospective clinical trial (n=20 plagiocephaly, n=10 brachycephaly, n=20 combination). A random distribution was performed for treatment with the bedding pillow alone (n=25) or with stretching exercises (n=25) for 6 weeks. Anthropometric caliper measurements were done before and after that interval. Cranial vault asymmetry index (CVAI) and cranial index (CI) were calculated and analyzed using a descriptive statistical general linear model.

RESULTS

ΔCVAI in the stretching group was 2.09% for plagiocephaly and 2.34% for combined head deformities. Using the bedding pillow, ΔCVAI was 3.01% in plagiocephal children and 2.86% for combined head deformity. The ΔCI in the stretching group was 0.94% for isolated brachycephal children and 2.24% for combined head deformity. ΔCI in the pillow group was 3.63% for brachycephaly and 3.23% in children with combined head deformities, respectively.

CONCLUSIONS

Bedding pillows and stretching exercises both resulted in improvements in positional cranial deformation. For children with combined plagiocephaly and brachycephaly, improvement in cranial asymmetry was slightly greater when using bedding pillows versus stretching.

Evidence-based care of the child with deformational plagiocephaly, part II: management

Non-synostotic deformational plagiocephaly (DP) is a common condition that affects as many as one in five infants in the first 2 months of life. The purpose of this article, the second in a two-part series, is to present a synthesis of the evidence related to management of deformational plagiocephaly and an evidence-based clinical decision tool for multidisciplinary management of DP. We systematically reviewed and graded the literature on management of DP from 2000 to 2011 based on level of evidence and quality. The evidence suggests that although many cases of DP will improve over time, conservative management strategies such as repositioning, physical therapy, and cranial molding devices can safely and effectively minimize the degree of skull asymmetry when implemented in the first year of life. Outcomes are best when the timing of diagnosis and severity of asymmetry guide decision making related to interventions and referrals for DP. Prevention and management of early signs of DP are best achieved in a primary care setting, with multidisciplinary management based on the needs of the child and the goals of the family.

HElmet therapy Assessment in infants with Deformed Skulls (HEADS): protocol for a randomised controlled trial

BACKGROUND

In The Netherlands, helmet therapy is a commonly used treatment in infants with skull deformation (deformational plagiocephaly or deformational brachycephaly). However, evidence of the effectiveness of this treatment remains lacking. The HEADS study (HElmet therapy Assessment in Deformed Skulls) aims to determine the effects and costs of helmet therapy compared to no helmet therapy in infants with moderate to severe skull deformation.

METHODS/DESIGN

Pragmatic randomised controlled trial (RCT) nested in a cohort study. The cohort study included infants with a positional preference and/or skull deformation at two to four months (first assessment). At 5 months of age, all children were assessed again and infants meeting the criteria for helmet therapy were asked to participate in the RCT. Participants were randomly allocated to either helmet therapy or no helmet therapy. Parents of eligible infants that do not agree with enrolment in the RCT were invited to stay enrolled for follow up in a non-randomisedrandomised controlled trial (nRCT); they were then free to make the decision to start helmet therapy or not. Follow-up assessments took place at 8, 12 and 24 months of age. The main outcome will be head shape at 24 months that is measured using plagiocephalometry. Secondary outcomes will be satisfaction of parents and professionals with the appearance of the child, parental concerns about the future, anxiety level and satisfaction with the treatment, motor development and quality of life of the infant. Finally, compliance and costs will also be determined.

DISCUSSION

HEADS will be the first study presenting data from an RCT on the effectiveness of helmet therapy. Outcomes will be important for affected children and their parents, health care professionals and future treatment policies. Our findings are likely to influence the reimbursement policies of health insurance companies.Besides these health outcomes, we will be able to address several methodological questions, e.g. do participants in an RCT represent the eligible target population and do outcomes of the RCT differ from outcomes found in the nRCT?

TRIAL REGISTRATION

ISRCTN18473161.

Evidence-based care of the child with deformational plagiocephaly, Part I: assessment and diagnosis

Non-synostotic deformational plagiocephaly (DP) is head asymmetry that results from external forces that mold the skull in the first year of life. Primary care providers are most likely to encounter DP when infants present for well-child care, and for this reason it is important that providers be competent in assessing, diagnosing, and participating in the prevention and management of DP. The purpose of this two-part series on DP is to present an overview of assessment, diagnosis, and evidence-based management of DP for health care providers. In Part I we provide a brief background of DP and associated problems with torticollis and infant development, and we present strategies for visual and anthropometric assessment of the infant with suspected DP. We also provide tools for differentiating DP from craniosynostosis and for classifying the type and severity of lateral and posterior DP. Part II (to be published in a future issue of the Journal of Pediatric Health Care) provides a synthesis of current evidence and a clinical decision tool for evidence-based management of DP.

Brain volume and shape in infants with deformational plagiocephaly

PURPOSE

Infants with deformational plagiocephaly (DP) have been shown to exhibit developmental delays relative to unaffected infants. Although the mechanisms accounting for these delays are unknown, one hypothesis focuses on underlying differences in brain development. In this study, we used MRI to examine brain volume and shape in infants with and without DP.

METHODS

Participants included 20 infants with DP (mean age = 7.9 months, SD = 1.2; n = 12 male) and 21 controls (mean age = 7.9 months, SD = 1.3; n = 11 male). Measures included volumes of the total brain and cerebellum; midsagittal areas of the corpus callosum and cerebellar vermis; and linear distance measures used to quantify the shape of selected brain structures. We also evaluated the association between shape measures and developmental scores on the Bayley Scales of Infant and Toddler Development-III (BSID-III).

RESULTS

Brain volume did not distinguish cases and controls (p = .214-.976). However, cases exhibited greater asymmetry and flattening of the posterior brain (p < .001-.002) and cerebellar vermis (p = .035), shortening of the corpus callosum (p = .012), and differences in the orientation of the corpus callosum (p = .005). Asymmetry and flattening of brain structures were associated with worse developmental outcomes on the BSID-III.

CONCLUSIONS

Infants with DP show differences in brain shape, consistent with the skull deformity characteristic of this condition, and shape measures were associated with infant development. Longitudinal studies, beginning in the neonatal period, are needed to clarify whether developmental effects precede or follow brain deformation.

Prevalence of Positional Plagiocephaly in Teens Born after the “Back to Sleep” Campaign

Objectives. To determine the prevalence of positional plagiocephaly and brachycephaly in teenagers born after the “Back to Sleep” campaign but before orthotic helmet treatment became widely available and to provide long-term outcomes data on those children with plagiocephaly who were not treated with remolding therapy.

Study Design. Cross-sectional analysis.

Setting. Local high schools in the Minneapolis–St Paul Metro area.

Subjects and Methods. Subjects were selected if they attended participating high schools and were born after the Back to Sleep campaign began. Skull measurements, including transcranial diameter, length, and width, were taken. Overall facial appearance was inspected for any apparent abnormal characteristics. Cranial vault asymmetry and cephalic index were calculated for each participant. Plagiocephaly was diagnosed if cranial vault asymmetry was >1 cm. Brachycephaly was diagnosed if the cephalic index was >0.90.

Results. There were 1045 participants, ranging from 12 to 17 years old, with an average age of 15.7 years. The prevalence of plagiocephaly was 1.1%. The prevalence of brachycephaly was 1.0%. The overall prevalence of a deformational cranial abnormality was 2.0%. Of those who met diagnostic criteria of plagiocephaly or brachycephaly, 38.1% were noted to have abnormal facial characteristics.

Conclusions. The prevalence of plagiocephaly and brachycephaly in teenagers is significantly lower than the 20% to 48% prevalence found in infants in previous studies, suggesting most children will outgrow the condition without intervention. Additional studies are needed to determine which patients might benefit from treatment and which will likely have resolution without intervention, since treating all infants who meet criteria results in significant overtreatment.

Positional plagiocephaly: what the pediatrician needs to know. A review

INTRODUCTION

Positional or deformational plagiocephaly is the most common type of cranial asymmetry in infancy and has become more prevalent after the introduction of the "Back to Sleep" campaign in Western countries. However, the supine position cannot be considered as the only etiologic factor and different predisposing variables have been investigated in the last few years.

DISCUSSION

The pediatrician should correctly diagnose this condition and exclude the possibility of craniosynostosis in any child with plagiocephaly in order to optimize management and reduce potential morbidity associated with different conditions other than positional ones. In addition, the pediatrician needs to be able to educate parents on methods to proactively decrease the likelihood of the development of occipital flattening, initiate appropriate management, and make referrals when necessary.

Positional plagiocephaly

Cranial asymmetry occurring as a result of forces that deform skull shape in the supine position is known as deformational plagiocephaly. The risk of plagiocephaly may be modified by positioning the baby on alternate days with the head to the right or the left side, and by increasing time spent in the prone position during awake periods. When deformational plagiocephaly is already present, physiotherapy (including positioning equivalent to the preventive positioning, and exercises as needed for torticollis and positional preference) has been shown to be superior to counselling about preventive positioning only. Helmet therapy (moulding therapy) to reduce skull asymmetry has some drawbacks: it is expensive, significantly inconvenient due to the long hours of use per day and associated with skin complications. There is evidence that helmet therapy may increase the initial rate of improvement of asymmetry, but there is no evidence that it improves the final outcome for patients with moderate or severe plagiocephaly.

Developing guidelines for child health care nurses to prevent nonsynostotic plagiocephaly: searching for the evidence

The aim of the project was to develop guidelines for nurses that can be incorporated into the Swedish child health care program to prevent nonsynostotic plagiocephaly in infants while still following sudden infant death syndrome preventive measures. Guidelines were developed by reviewing the literature, compiling evidence, appraising recommendations, and formulating a condensed version of relevant information for nurses. The guidelines were tested clinically in a Swedish pilot project.