Deformational plagiocephaly: diagnosis, prevention, and treatment

Another look at “tummy time” for primary plagiocephaly prevention and motor development

It is three decades since it was recommended that infants sleep on the back to reduce risk of sudden unexpected infant death (SUID). The SUID prevention program is known as "back to sleep" or "safe sleeping", and this initiative is not questioned. Sleeping on the back is associated with, but not the cause of, the development of infant positional plagiocephaly, also known as deformational or a non-synostotic misshapen head when the skull sutures are open, not fused. This paper provides a synthesis of the history and impact of positional plagiocephaly. It includes a scoping review of plagiocephaly prevention facilitating motor development and reveals few articles on primary prevention which aims to prevent it developing in the first place. It is concerning that preschool-aged children with a history of infant plagiocephaly continued to receive lower developmental scores, particularly in motor development, than unaffected controls, and this may be a marker of developmental delay. Tummy-time (prone) for play is the mainstay of plagiocephaly prevention advice to minimize development of plagiocephaly and to facilitate infant motor development, particularly head control. While tummy-time has shown benefit for infant development, there is limited evidence of its effectiveness in preventing plagiocephaly and some evidence that it promotes only prone-specific motor skills. Most of the published literature is concerned with treatment post-diagnosis, in the form of reviews, or clinical notes. There is a plethora of opinion articles reinforcing tummy-time from birth for plagiocephaly prevention. The review shows that there are gaps in advice for early infant development of head control. An accepted test of head control in infants is "pull to sit" from supine which demonstrates antigravity strength of the neck flexors and coordination of the head and neck when the infant is drawn to sit from supine. This motor skill was cited as achievable by 4 months in the earliest paper on plagiocephaly in 1996. Physical therapists and others should revisit the mechanism of early infant head control development against gravity, particularly antigravity head, neck and trunk coordinated flexion movement in supine, as there has been little attention to early facilitation of this motor skill as a plagiocephaly prevention strategy. This may be achieved by considering "face time" as well as tummy time for primary prevention of plagiocephaly.

Active Cervical Range of Motion in Babies with Positional Plagiocephaly: Analytical Cross-Sectional Study

Positional plagiocephaly (PP) is a general term describing cranial distortion from pre- or postnatal forces on the infant head. Abnormal intrauterine forces, multiple births, primiparous mothers, obstetric interventions, prematurity, male sex, excessive time lying in the supine position, and mobility restrictions of the cervical spine have been considered as the main predisposing factors. The objective was to investigate the association between the severity of PP and the active cervical rotation and to analyze the influence of predisposing factors in babies with PP. An analytical cross-sectional study was performed on 74 babies with moderate PP. Clinical and demographic data, cranial vault asymmetry, and active cervical rotation range of motion (ROM) were measured. Associations were analyzed with generalized linear models. The mean age was 16.8 ± 5.0 weeks, and 56.8% were male. A restriction in the ROM of active cervical rotation, especially to the left side, was observed. Our models showed that cranial asymmetry was related with left active cervical rotation ROM (p = 0.034) and with being transported in a pushchair (p < 0.001). Conclusions: An increased severity of PP was related with being transported in a baby pushchair and with a reduced active cervical rotation ROM toward the most restricted side.

Symmetry and Aesthetics in Dentistry

Animal bodies in general and faces in particular show mirror symmetry with respect to the median-sagittal plane, with exceptions rarely occurring. Bilateral symmetry to the median sagittal plane of the body also evolved very early. From an evolutionary point of view, it should therefore have fundamental advantages, e.g., more effective locomotion and chewing abilities. On the other hand, the recognition of bilaterally symmetric patterns is an important module in our visual perception. In particular, the recognition of faces with different spatial orientations and their identification is strongly related to the recognition of bilateral symmetry. Maxillofacial surgery and Dentistry affect effective masticatory function and perceived symmetry of the lower third of the face. Both disciplines have the ability to eliminate or mitigate asymmetries with respect to form and function. In our review, we will demonstrate symmetric structures from single teeth to the whole face. We will further describe different approaches to quantify cranial, facial and dental asymmetries by using either landmarks or 3D surface models. Severe facial asymmetries are usually caused by malformations such as hemifacial hyperplasia, injury or other diseases such as Noma or head and neck cancer. This could be an important sociobiological reason for a correlation between asymmetry and perceived disfigurement. The aim of our review is to show how facial symmetry and attractiveness are related and in what way dental and facial structures and the symmetry of their shape and color influence aesthetic perception. We will further demonstrate how modern technology can be used to improve symmetry in facial prostheses and maxillofacial surgery.

Rethinking Farkas: Updating Cephalic Index Norms in a Large, Diverse Population

BACKGROUND

Cephalic index, the ratio of head width to length, is one normative indicator used by insurers to derive criteria for plagiocephaly helmet authorization. Current norms were established by a small sample of white children in the 1987 Farkas and Munro data set. This study establishes updated cephalic index values for infants and children in a large, diverse patient population.

METHODS

Children aged 0 to 3 months, 3 to 6 months, 9 to 12 months, 2 to 3 years, and 12 to 14 years were recruited at their well-child appointment. Cephalic index was calculated for each age group and compared to previously established norms.

RESULTS

Eight hundred seventy patients met inclusion criteria. The means for boys and girls between 0 and 6 months were 83.5 (n = 155, SD 6.01) and 83.5 (n = 191, SD 5.80), respectively. Established means for boys and girls between 0 and 6 months were 74.4 (n = 38, SD 5.2) and 74.3 (n = 49, SD 6.1), respectively. The difference between norms is highly statistically significant (p < 0.0001). For this age range, insurance criteria for a helmet is >83.7 for boys and >82.7 for girls. Using previous norms, 74 boys (44.6 percent) and 104 girls (54.5 percent) would meet criteria for a helmet under current guidelines.

CONCLUSIONS

The mean cephalic index of children has changed. The reasons could include diversifying populations in the United States and the introduction of the Back to Sleep campaign. Over 50 percent of children may inappropriately meet criteria for a helmet based on prior norms. Updating norms could change the definition of plagiocephaly for a helmet orthosis.

Assessing the quality of life in infants with deformational plagiocephaly

This was a parent-reported outcome study on the impact of helmet therapy on the quality of life of infants with deformational plagiocephaly and their caregivers. Using survey-based analysis, we compared the quality of life in infants with deformational plagiocephaly with a cohort of their healthy peers. In addition, we compared infant quality of life before and after helmet therapy to evaluate the impact of this mainstay therapy for deformational plagiocephaly. Our results demonstrated that infants with plagiocephaly and their caregivers had a significantly decreased quality of life compared with healthy controls. This reframes our understanding of deformational plagiocephaly and emphasizes the need for therapeutic intervention in these individuals. A common therapeutic option - helmet remolding therapy - was shown to have no negative impact on quality of life, underscoring this as an appropriate therapeutic option. These data will allow us to counsel our future parents more effectively regarding the impact of deformational plagiocephaly and helmet therapy.

Delayed Motor Development and Infant Obesity as Risk Factors for Severe Deformational Plagiocephaly: A Matched Case-Control Study

The prevalence of deformational plagiocephaly (DP) has increased since the recommendation of positioning infants to their back during sleeping and is affected by various biological and environmental factors. This study aimed to investigate associations between DP and perinatal or infant characteristics, including obesity. This case-control study included 135 infants (81 males) aged 2-12 months who were diagnosed with DP using calculated cranial vault asymmetric index and cranial index and 135 age- and sex-matched controls. Motor development was evaluated using the Alberta Infant Motor Scale, and obesity was defined by body mass index. Univariate and multivariate logistic regression models were used to assess potential risk factors for DP and its severity. One hundred thirty-five infants with DP were divided into the following three subgroups according to severity indicated by the cranial vault asymmetry index: mild to moderate group (n = 87, 64.4%), severe group (n = 48, 35.6%), and a combined plagiocephaly and brachycephaly group (n = 79, 58.5%). Independent risk factors significantly associated with development of DP were bottle-only feeding (adjusted odds ratio (aOR) = 4.65; 95% CI: 2.70-8.00), little tummy time when awake (aOR = 3.51, 95% CI: 1.71-7.21), delay of motor development (aOR = 2.85, 95% CI: 1.08-7.49), and obesity at diagnosis (aOR = 2.45, 95% CI: 1.02-5.90). Among these risk factors, delay of motor development (aOR = 4.91, 95% CI: 1.46-16.51) and obesity at diagnosis (aOR = 4.10, 95% CI: 1.42-11.90) were particularly related to severe DP. In conclusion, this study confirms that DP risk is positively associated with bottle-only feeding, infrequent tummy time, and delayed development of motor milestones. Notably, this study demonstrates infant obesity as a new risk factor for DP. Our findings suggest that obesity should be identified early and managed comprehensively in infants with DP.

Pregnancy Outcomes in Men and Women Treated With Teriflunomide. A Population-Based Nationwide Danish Register Study

Background: The majority of persons diagnosed with multiple sclerosis (MS) experience their first MS symptoms in the reproductive age. Teriflunomide (TFL, Aubagio), was first released in Denmark for relapsing-remitting MS in December 2013. TFL treatment is contraindicated in women of childbearing potential who are not using reliable contraception. TFL can be transmitted via semen and a low risk of male-mediated embryo-fetal toxicity is described. Objective: To report pregnancy outcomes of TFL-treated women and partners to TFL-treated men: gestation week. Methods: Prospective cohort study comparing pregnancy outcomes of TFL-treated men and women, matched on age at conception, 1:4 with controls from the general population. Data on TFL-treated patients treated 1st of January 2014-31st of December 2016 for at least 30 consecutive days prior to conception, and with conception occurring latest 2 years after treatment discontinuation were extracted from The Danish Multiple Sclerosis Registry and merged with several national reproductive registries. Logistic regression was used to analyse the association between TFL exposure and any adverse event. Results: A total of 31 pregnancies were recorded, 13 women and 18 of partners to a TFL-treated man. All 18 partners of TFL-treated men completed their pregnancies: livebirth (18), gestation time >37 weeks (17), gestation time 33-36 weeks (1), normal birth weight (18), spontaneous and elective abortion (0), congenital malformation (plagiocephali) (1), normal delivery (14), induced delivery (2), cesarean section (2), Apgar score ≥7 (18). Among the 13 pregnancies in women exposed to TFL: elective abortion (11), spontaneous abortion (0), livebirth (2), gestation time >37 weeks (2), normal birth weight (2), congenital malformations (0), normal delivery (1), induced delivery (1), Apgar score ≥7 (2). The TFL group was associated with a 22% reduction in the odds of any adverse event relative to controls, although this association was not significant (OR 0.78; 95% CI 0.16-3.72, p = 0.753). Conclusion: Pregnancy outcomes were consistent with those of the general population. The malformation reported of the partner to a TFL-treated man is comparable to the rate of plagiocephaly reported in Denmark.

Prevalence and characteristics of positional plagiocephaly in healthy full-term infants at 8-12 weeks of life

Positional plagiocephaly (PP) denotes flattening of the skull that occurs frequently in healthy infants. Aim of this study was to estimate the prevalence of positional plagiocephaly and to identify the risk factors in a cohort of healthy infants in order to help prevention of PP. In a prospective design, all healthy full-term infants, ranging from 8 to 12 weeks of age, who presented at the public immunization clinic in Ferrara, were eligible for the study. After obtaining informed consent, we interviewed the parents and examined the infants using the Argenta's assessment tool. Of 283 infants examined, 107 (37.8%) were found to have PP at 8-12 weeks of age. In 64.5%, PP was on the right side, 50.5% were male and 15% presented also with brachycephaly. Risk factors significantly associated were lower head circumference, advanced maternal age, Italian compared to African, and supine sleep position, in particular for infants born at 37 weeks, preference for one side of the head. In logistic regression, risk factors significantly associated were lower birth weight, advanced maternal age, and supine sleep position.

CONCLUSIONS

Positional plagiocephaly is a common issue faced by pediatricians; our results reinforce the need of improving prevention both of sudden infant death and positional plagiocephaly, through uniform messages provided prenatally and postnatally by different health professionals. "What is Known:" •The incidence of positional plagiocephaly varies due to population studied and measuring methods. •Different factors are considered in the literature as being associated to positional plagiocephaly (infant factors, obstetric factors, infant care practices, sociodemographic factors). "What is New:" •This is one of the few European studies quantifying positional plagiocephaly prevalence in a population of unselected healthy infants. •In this study, positional plagiocephaly is confirmed as a common issue, related to some factor (as supine sleep position and positional head prevalence) that should be addressed in pre and postnatal counseling. •The prone sleepers rate in our population highlight the need to improve parental awareness regarding SIDS prevention, in particular in borderline gestational age.

Positional plagiocephaly is associated with sternocleidomastoid muscle activation in healthy term infants

PURPOSE

To explore the relationship between sternocleidomastoid activation and positional plagiocephaly in healthy full term infants.

METHODS

Participants were 82 infants from a regionally based-longitudinal study of infant development. Sternocleidomastoid (SCM) activation was assessed using active head-righting responses of body-on-head with and against gravity and head-on-body against gravity at 3, 6 and 9 weeks. Plagiocephaly was assessed using the Modified Cranial Vault Asymmetry Index (mCVAI) at 9 weeks.

RESULTS

More severe plagiocephaly was associated with more severe asymmetry in active head-righting responses at all ages (p < 0.001). Greater right-sided occipital flatness was related to stronger contralateral/left SCM activation at 3 and at 9 weeks (p = 0.008). Greater left-sided occipital flatness was related to stronger contralateral/right SCM activation at 3 weeks (p = 0.004). In infants with any right-sided occipital flatness, the mCVAI was greater in infants with asymmetrical gravity assisted body-on-head responses at 3 weeks (mCVAI = 4.31 (2.01)%, 95% CI 2.87-5.75) compared to those with symmetrical responses (mCVAI = 2.64 (1.66)%, 95% CI 2.06-3.22) (p = 0.011).

CONCLUSIONS

Sternocleidomastoid activation asymmetry is a significant contributor to plagiocephaly development by 9 weeks of age due to stronger contralateral SCM activation. Active head-righting responses are appropriate to assess sternocleidomastoid activation in infants under 2 months of age.

Diagnosis of infant synostotic and nonsynostotic cranial deformities: a review for pediatricians

Objective:

To review the current comprehensive care for nonsyndromic craniosynostosis and nonsynostotic cranial deformity and to offer an overall view of these craniofacial conditions.

Data source:

The review was conducted in the PubMed, SciELO, and LILACS databases without time or language restrictions. Relevant articles were selected for the review.

Data synthesis:

We included the anatomy and physiology of normal skull development of children, discussing nuances related to nomenclature, epidemiology, etiology, and treatment of the most common forms of nonsyndromic craniosynostosis. The clinical criteria for the differential diagnosis between positional deformities and nonsyndromic craniosynostosis were also discussed, giving to the pediatrician subsidies for a quick and safe clinical diagnosis. If positional deformity is accurately diagnosed, it can be treated successfully with behavior modification. Diagnostic doubts and craniosynostosis patients should be referred straightaway to a multidisciplinary craniofacial center.

Conclusions:

Pediatricians are in the forefront of the diagnosis of patients with cranial deformities. Thus, it is of paramount importance that they recognize subtle cranial deformities as it may be related to premature fusion of cranial sutures.

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.

Diagnosis of infant synostotic and nonsynostotic cranial deformities: a review for pediatricians

OBJECTIVE

To review the current comprehensive care for nonsyndromic craniosynostosis and nonsynostotic cranial deformity and to offer an overall view of these craniofacial conditions.

DATA SOURCE

The review was conducted in the PubMed, SciELO, and LILACS databases without time or language restrictions. Relevant articles were selected for the review.

DATA SYNTHESIS

We included the anatomy and physiology of normal skull development of children, discussing nuances related to nomenclature, epidemiology, etiology, and treatment of the most common forms of nonsyndromic craniosynostosis. The clinical criteria for the differential diagnosis between positional deformities and nonsyndromic craniosynostosis were also discussed, giving to the pediatrician subsidies for a quick and safe clinical diagnosis. If positional deformity is accurately diagnosed, it can be treated successfully with behavior modification. Diagnostic doubts and craniosynostosis patients should be referred straightaway to a multidisciplinary craniofacial center.

CONCLUSIONS

Pediatricians are in the forefront of the diagnosis of patients with cranial deformities. Thus, it is of paramount importance that they recognize subtle cranial deformities as it may be related to premature fusion of cranial sutures.

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.

Uvular malformation in the presence of deformational plagiocephaly

BACKGROUND

Deformational plagiocephaly is cranial asymmetry caused by external forces on the skull. Deformational plagiocephaly is seen in 5% to 48% of healthy newborns. Incomplete uvular fusion, in contrast, is one of many uvular malformations. The incidence of all degrees of incomplete uvular fusion is approximately 1% in healthy children. Bifid uvula is a malformation that is often considered a microform cleft palate or a marker for submucous cleft palate.

METHODS

This is a retrospective study of patients with deformational plagiocephaly seen at the Upstate Cleft and Craniofacial Center between January 1, 2006, and September 30, 2011. Patients were identified by the International Classification of Diseases, Ninth Revision code for plagiocephaly. Seventy-nine patients were excluded with craniosynostosis and syndromic diagnoses. One hundred forty-six patients with deformational plagiocephaly were included in the study. Data were collected for sex, age at presentation, parity, multiple births, delivery, oligohydramnios, cephalohematoma, uterine abnormalities, fetal position, and intrauterine growth restriction. Clinical findings were collected including location of cranial flattening and uvular malformations.

RESULTS

Twenty-four of 146 patients with deformational plagiocephaly had incomplete fusion of the uvula ranging from complete bifid uvula to a notched uvular tip (16.4%). This association was statistically significant (odds ratio, 18; 95% confidence interval, 11.1-28.9). Most patients (62.3%) were male. We recorded primiparity (44.5%), multiple births (17.1%), vacuum-assisted delivery (6.2%), cesarean section (36.3%), oligohydramnios (4.1%), uterine abnormalities (2.1%), abnormal fetal position (3.4%), and intrauterine growth restriction (1.4%). Ten of the 24 patients with plagiocephaly and uvular malformation were seen for an initial consultation only in our chart system. Of the remaining 14 patients with follow-up, none had recorded signs or symptoms of velopharyngeal insufficiency.

CONCLUSIONS

The incidence of incomplete uvular fusion in infants with deformational plagiocephaly is 16.4%, which is significantly higher than the approximate 1% incidence reported in the general population. This is the first report of uvular malformation in the presence of deformational plagiocephaly.

Analysis of Facial Asymmetry in Deformational Plagiocephaly Using Three-Dimensional Computed Tomographic Review

Background

Infants with deformational plagiocephaly (DP) usually present with cranial vault deformities as well as facial asymmetry. The purpose of this study was to use three-dimensional anthropometric data to evaluate the influence of cranial deformities on facial asymmetry.

Methods

We analyzed three-dimensional computed tomography data for infants with DP (n=48) and without DP (n=30, control). Using 16 landmarks and 3 reference planes, 22 distance parameters and 2 angular parameters were compared. This cephalometric assessment focused on asymmetry of the orbits, nose, ears, maxilla, and mandible. We then assessed the correlation between 23 of the measurements and cranial vault asymmetry (CVA) for statistical significance using relative differences and correlation analysis.

Results

With the exception of few orbital asymmetry variables, most measurements indicated that the facial asymmetry was greater in infants with DP. Mandibular and nasal asymmetry was correlated highly with severity of CVA. Shortening of the ipsilateral mandibular body was particularly significant. There was no significant deformity in the maxilla or ear.

Conclusion

This study demonstrated that the cranial vault deformity in DP is associated with facial asymmetry. Compared with the control group, the infants with DP were found to have prominent asymmetry of the nose and mandible.

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.

Outcome analysis after helmet therapy using 3D photogrammetry in patients with deformational plagiocephaly: the role of root mean square

Deformational plagiocephaly (DP) is a multifactorial non-synostotic cranial deformity with a reported incidence as high as 1 in 7 infants in North America. Treatment options have focused on non-operative interventions including head repositioning and the use of an orthotic helmet device. Previous studies have used linear and two dimensional outcome measures to assess changes in cranial symmetry after helmet therapy. Our objective was to demonstrate improvement in head shape after treatment with a cranial molding helmet by using Root Mean Square (RMS), a measure unique to 3D photogrammetry, which takes into account both changes in volume and shape over time. Three dimensional photographs were obtained before and after molding helmet treatment in 40 infants (4-10 months old) with deformational plagiocephaly. Anatomical reference planes and measurements were recorded using the 3dMD Vultus(®) analysis software. RMS was used to quantify symmetry by superimposing left and right quadrants and calculating the mean value of aggregate distances between surfaces. Over 95% of the patients demonstrated an improvement in symmetry with helmet therapy. Furthermore, when the sample of infants was divided into two treatment subgroups, a statistically significant correlation was found between the age at the beginning of treatment and the change in the RMS value. When helmet therapy was started before 7 months of age a greater improvement in symmetry was seen. This work represents application of the technique of RMS analysis to demonstrate the efficacy of treatment of deformational plagiocephaly with a cranial molding helmet.

Complications associated with molding helmet therapy for positional plagiocephaly: a review

Molding helmet therapy is a widely accepted treatment for positional plagiocephaly that is generally considered to be low risk. Multiple large outcome studies have shown good results, but adverse events are rarely reported. The literature on helmet therapy was reviewed to clarify the clinical experience with associated complications. Although significant complications were extremely rare, there was a large degree of variability in detection of lesser problems such as minor skin irritation. Patients with a primarily brachycephalic morphology may be at higher risk for poorly fitting orthoses. Most reported complications are minor and self-limited. Maintenance of good helmet hygiene appears to be the most effective strategy for reducing or eliminating complications.

Clinical profile and evolution of infants with deformational plagiocephaly included in a conservative treatment program

PURPOSE

The aim of this study was to evaluate the results of a conservative intervention in infants with plagiocephaly according to their specific clinical profile.

METHODS

Prospective clinical trial in which 104 infants with plagiocephaly accompanied or not by congenital or positional torticollis were referred to Early Care and Monitoring Unit (USAT) of San Cecilio Hospital in Granada, between 2009 and 2012. All the infants, grouped into three categories of severity, were included in the physiotherapy protocol until adequate craniofacial morphology and motor development were achieved. The study included an assessment of parents and infants. Parents were assessed with a questionnaire about the mother's medical history and birth-related issues. The assessment of infants included anthropometric measures, a positional assessment, the observation of the head, the assessment of severity, and motor development.

RESULTS

Birth characteristics were similar in the total sample but showed different clinical profiles according to treatment aspects. More specifically, infants with severe plagiocephaly were referred to treatment later and spent more time in treatment; use of an orthotic helmet was also more prevalent in this category. There were also significant differences (P < 0.05) in the acquisition of specific gross motor skills depending on the severity of plagiocephaly.

CONCLUSION

The findings suggest that the physiotherapy protocol presented is effective to correct plagiocephaly. Severity of plagiocephaly is a marker that should be taken into account when designing actions aimed at improving gross motor skill development.

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.

Deformational plagiocephaly and orthotic treatment: indications and limitations

PURPOSE

As the incidence of deformational plagiocephaly (DP) has risen, so has the demand on clinicians to make appropriate treatment recommendations. While knowledge of risk factors and natural history continue to evolve, there is uncertainty and controversy regarding intervention approaches. The purpose of this report is to review current treatment approaches for DP, in particular the use of orthotic helmets.

METHODS

A narrative literature review was conducted to summarize current evidence supporting preventative measures and re-positional and orthotic interventions.

RESULTS

When started early at under 2 months of age, positional efforts and 'tummy time' can be effective in preventing and improving DP, but these strategies need to be better promoted to caregivers. The timing, severity and parental concerns as indicators for orthotic treatment are reviewed. Limitations discussed include high cost, lower level of evidence and poor understanding of long-term outcomes and caregiving implications.

CONCLUSION

For optimal outcome, current evidence supports use of repositioning in young infants and start of orthotic helmet treatment for infants with significant DP at 4-6 months. Further research is needed to better understand the parameters for use (stratified by age and severity), long-term outcomes and natural history and the impact on caregiving, as well as the cultural significance of head shape.

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.

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.

Consequences of the "back to sleep" program in infants

Sudden infant death syndrome (SIDS) is the third leading cause of infant mortality in the United States and the leading cause of death among infants 28-364 days of age. The "Back to Sleep" program was implemented in 1992 to promote supine sleeping in efforts to prevent SIDS. Along with this implementation came several consequences that are avoidable in infants. The purposes of this article are to describe the Back to Sleep program and its intended purpose, to identify the adverse consequences, and to develop a teaching program for nurse practitioners to use with parents that will both promote safe sleeping and reduce the untoward consequences of the back to sleep program while maintaining the integrity of the SIDS prevention advice.

Stretching treatment for infants with congenital muscular torticollis: physiotherapist or parents? A randomized pilot study

OBJECTIVE

To investigate the time needed to achieve a good result in the range of motion (ROM) in the neck for infants with congenital muscular torticollis (CMT).

DESIGN

Comparison of stretching treatments performed by physical therapists and parents.

PARTICIPANTS

Twenty infants (10 female and 10 male) with CMT.

METHOD

The infants were randomly assigned to 1 of 2 groups. Stretching treatment was continued until a good ROM was obtained in both rotation (≥ 90°) and lateral flexion (no side difference). The main outcome measurement was treatment time. The infants were evaluated for ROM in rotation and lateral flexion, muscle function in the lateral flexor muscles of the neck, plagiocephaly, and head tilt.

RESULTS

The time needed to achieve a good result according to the ROM in the neck was significantly shorter (P < .001) in the physical therapist group than in the parent group. Symmetrical head posture was achieved sooner (P = .03) in the physical therapist group.

CONCLUSION

Infants with CMT gained good ROM and symmetric head posture approximately 2 months sooner when treated by an experienced physical therapist; however, interpretation of the results of this small study should be guarded. Further studies are needed to confirm these results.

Treatment of Plagiocephaly with Helmet Molding Therapy: Do Actual Results Mimic Perception?

Purpose

Actual and perceived improvements from helmet molding therapy for deformational plagiocephaly are demonstrated here. Effective communication of these data by craniofacial teams can help avoid unrealistic expectations and inform parents of expected outcomes.

Methods

Parents of 61 patients with plagiocephaly were asked to rate their children's head shape and ear position before and after helmet therapy (a score of 1 being abnormal and 10 being normal). Topographic laser head scans for an aged-matched cohort of 91 patients with deformational plagiocephaly were acquired. Cephalic ratio, overall symmetry ratio, radial symmetry index, ear offset, and left and right oblique were recorded before and after molding. The cranial vault asymmetry index (CVSI) score was calculated.

Results

Parent ratings before and after molding, respectively, were head shape 2.99 ± 1.50 (mean ± SD) versus 7.88 ± 1.64 (p < .0001) and ear position 3.75 ± 2.5 versus 7.73 ± 2.34 (p < 0.0001). Measurements before and after molding were cephalic ratio 0.89 ± 0.07 versus 0.87 ± 0.08 (p < .0001), overall symmetry index 0.87 ± 0.05 versus 0.90 ± 0.04 (p < .0001), radial symmetry index 59.9 ± 26.9 mm versus 46.3 ± 25.1 mm (p < .0001), CVSI 7.2 ± 3.75 versus 4.8 ± 2.8 (p < .0001), and ear offset 5.7 versus 5.5 mm (p = .58).

Conclusions

Helmet molding produces reproducible changes in head shape. Despite relatively small actual changes on topographic laser imaging, parents perceive a large correction in head shape and ear position following helmet molding. Craniofacial teams can use these data and head scans before helmet molding to provide parents with realistic expectations for the outcome of their child's helmet molding therapy.

Divided parietal bone in plagiocephaly

Supernumerary cranial sutures represent a rare cause of plagiocephaly. In the case of an extra suture dividing the parietal bone, the presenting features are often inconsistent with the typical presentation of deformational or synostotic plagiocephaly. Disagreement exists as to how the presence of this suture affects the shape of the skull. We present a case of a supernumerary suture in the parietal bone leading to plagiocephaly and discuss the role this suture plays in cranial growth.

Hemangioma causing deformational plagiocephaly

Hemangioma is the most common tumor of infancy, occurring mostly in the head and neck region. Intervention during the proliferating phase is indicated if the lesion poses a threat to life or function. Posterior head and neck hemangioma causing deformational plagiocephaly is a further indication for intervention.

Obstetrical brachial plexus palsy

SUMMARY

In this article, the authors review their approach to evaluation, operative management, and reconstructive technique. Brachial plexus injuries in the newborn are usually managed nonoperatively. The timing and indications for primary surgery vary significantly between institutions. The motor examination is used to determine which infants would benefit from operative management. Patients are selected based on established criteria, such as the Toronto Test Score, applied at age 3 months. However, some cases are initially less clear, and we may recommend delaying operative management until age 6 months or as late as age 9 months if the child fails the cookie test. Neuroma excision, sural nerve grafting, and nerve transfers are performed when indicated by clinical motor examination. The use of selective motor nerve transfers, either in combination with nerve grafting or alone, has allowed nerve coaptations to be performed closer to the neuromuscular junction, which may further improve regeneration. Children undergoing primary surgery experience low rates of perioperative morbidity, and they experience gains in motor function until 3 or 4 years postoperatively, at which point recovery stabilizes.

A triage system for referrals of pediatric skull deformities

The clinical pathways for craniosynostosis and nonsynostotic skull deformity are entirely different. At the Dutch Craniofacial Center (DCFC), all patients were assessed in the same multidisciplinary craniofacial clinic, a common practice in countries with developed health care. However, the high volume of referrals of nonsynostotic cases frequently resulted in the capacity of these clinics being exceeded, with some patients being assessed in the general pediatric plastic surgery clinic instead. In these general clinics, not all the multidisciplinary team members are routinely present, so patients with craniosynostosis had to make a second journey for further assessment, causing inconvenience, expense, and potential delay in treatment. With triage at the community level unreliable and triage at clinic level inefficient, we decided to trial a triage system to increase efficiency and to ensure patients enter the correct clinical pathway earlier.The 2 craniofacial secretaries were issued with a flowchart to be completed for each new referral. The flowcharts were designed to triage the patients into true craniosynostosis with an appointment for the multidisciplinary clinic or nonsynostotic deformity with an appointment with the craniofacial nurse practitioner (CNP). During a 3-month period, 107 referrals were made. The triage category listed on the initial flowchart for each patient was compared, with the final diagnosis made in the multidisciplinary and CNP clinics.None of the patients triaged as nonsynostotic deformity on the flowcharts were found to be true craniosynostosis after clinical assessment by the CNP. Radiographic assessment or assessment by the craniofacial surgeons in the DCFC confirmed this.The flowchart questionnaire used at the DCFC is a highly sensitive and therefore safe method for detecting craniosynostosis. It has helped to improve efficiency by ensuring patients are seen in an appropriate setting.

Management of facial asymmetry

Asymmetries of the craniofacial region encompass a multitude of diverse and potentially complex abnormalities that may be the result of numerous causes. The expression and degree of asymmetry for a given condition, although a highly variable process, is the ultimate determinant of the nature of its treatment. This article highlights some of the key features and treatment strategies for various common facial asymmetries.

Comparison of a modifiable cranial cup versus repositioning and cervical stretching for the early correction of deformational posterior plagiocephaly

BACKGROUND

Deformational occipital flattening is the most common cause of abnormal head shape. Current treatment calls for repositioning and cervical stretching in infants younger than 5 months. The authors assessed the effectiveness of a modifiable cranial cup compared to repositioning and cervical stretching to correct early deformational plagiocephaly.

METHODS

This nonrandomized, prospective clinical trial used historical controls. The treatment and control groups consisted of infants, younger than 4 months, referred for deformational posterior plagiocephaly. The control children were managed by repositioning and cervical stretching exercises. An adjustable concave cranial cup was used in the treated group. Infants were examined at the initial and final visits by a single examiner. Calvarial asymmetry was measured using a large cranial caliper. Active head rotation and degree of rotational asymmetry were estimated to the nearest 10 degrees.

RESULTS

There were no statistically significant differences between the control (n = 23) and treatment groups (n = 24) with respect to gestational age at birth, age at initial visit, initial head rotational asymmetry, initial transcranial difference, final head rotational asymmetry, and age at final evaluation. Mean time between initial and final evaluation was 56.3 days for the treatment group and 61.6 days for the control group. The mean transcranial difference decreased from 11.2 to 3.5 mm in the treatment group, and from 9.0 to 8.0 mm in the control group (p = 0.000).

CONCLUSION

The cranial cup, a modifiable concave resting surface, is significantly more effective than repositioning and physical therapy for correcting early deformational plagiocephaly.

Effective correction of frontal cranial deformities using biodegradable fixation on the inner surface of the cranial bones during infancy

PURPOSE

Fixation of cranial bones in pediatric craniofacial surgery with biodegradable materials has developed into an accepted method. However, placing the fixation material on the outer surface of the cranial bone at the frontal cranium in infants can result in suboptimal cosmetic outcomes, as the plates and screws can be palpable. The placement of resorbable fixation devices on the inner surface of the skull would allow for less obvious fixation beneath the skin with a potentially superior cosmetic result. The authors report the use of such resorbable fixation devices on the inner or endocranial aspect of the cranium which appears to be novel.

MATERIALS AND METHODS

Ten patients with the mean age of 14 months (range 7-35 months) were treated with cranial remodeling using poly(lactide-co-glycolide) (PLGA) biodegradable fixation on the inner surface of the cranial bones. Five patients had trigonocephaly, four plagiocephaly, and one brachycephaly. All patients had 3D computed tomography (CT) and clinical photographs done preoperatively and postoperatively at follow-up. The outcome was judged at follow-up by clinical evaluation, photographs, 3D CT, and interview of the parents. The mean follow-up time was 3.5 years (range 0.5-6 years).

RESULTS

The primary recovery was uneventful in all cases. No wound infection occurred, but one patient had a minor skin necrosis which required a single revision operation to correct. The cosmetic outcome was scored as excellent, good, fair, or poor. There was no case with delayed union. Seven out of ten cases were judged as excellent and three as good, none as fair or poor.

CONCLUSIONS

The use of resorbable PLGA fixation devices on the inner aspect of the skull appears to provide a satisfactory cosmetic result in this small preliminary group of pediatric patients. Further long-term study of these materials in this specific location in a larger patient group is needed.

Long-term outcome of infants with positional occipital plagiocephaly

BACKGROUND

Despite much interest in positional (deformational) plagiocephaly, the natural history is unclear. The purpose of this study was to determine cosmetic and developmental outcomes at a minimum of 5 years of age in children diagnosed in infancy with positional plagiocephaly (PP) and the impact of cranial orthotic use.

METHODS

A questionnaire survey was sent to parents of children diagnosed with PP in infancy and now aged more than 5 years. A retrospective review of the child's clinic chart was performed of consenting families, and prospective follow-up was done when families agreed to return for assessment.

RESULTS

Of 278 eligible children with plagiocephaly, questionnaires were completed by 65 parents, and 27 brought their child for assessment. Participants and nonparticipants were similar. Cranial orthoses were used in 18 of 65 children. Parents perceived the cosmetic appearance of their child as "very abnormal" in 2, "mildly abnormal" in 25, and "normal" in 38. Residual asymmetry was noted by parents in 58%, but only 21% were concerned about appearance. In the last year, 7.7% of children commented about asymmetry of head, and 4.6% were teased occasionally. Thirty-three percent had received learning assistance, and 14% were in a special class. Long-term outcomes, as perceived by the parent or child, were no different between children with and without orthosis use.

CONCLUSIONS

The results allow better counselling of parents about outcome of infants with PP, reducing anxiety, and allowing more rational selection of management modality.

Nonsynostotic occipital plagiocephaly: factors impacting onset, treatment, and outcomes

BACKGROUND

Nonsynostotic occipital plagiocephaly remains a diagnosis of concern in infancy. This study evaluates factors affecting the onset, treatment, and outcomes of nonsynostotic occipital plagiocephaly.

METHODS

A retrospective chart review and telephone survey were performed. A posterior occipital deformation severity score was used. Factors such as demographics, behavioral and helmet therapy, feeding patterns, torticollis, multiple gestation pregnancies, prematurity, and congenital nonsynostotic occipital plagiocephaly were evaluated.

RESULTS

One hundred five infants were identified. Of these, 95 percent were Caucasian, 93 percent were from two-parent households, and 70 percent were from households earning more than $50,000. Repositioning was attempted in 95 percent, and 45 percent progressed to helmet therapy. When comparing change in posterior occipital deformation severity score with helmet therapy to repositioning, a difference was found (p < 0.05). Forty-nine percent of patients were breast-fed, and when compared with the general population, a difference was found (p < 0.05). Twenty percent of infants had torticollis, and when compared with population norms, a difference was found (p < 0.05). Twelve percent of patients were twins, and when compared with population norms, more twinning occurred (p < 0.05). Congenital nonsynostotic occipital plagiocephaly was found in 10 percent of patients and did not result in an increased risk of progression to helmet therapy.

CONCLUSIONS

This study demonstrates trends that may predict additional risks for developing nonsynostotic occipital plagiocephaly, including torticollis, plural births, and increased socioeconomic affluence. In addition, the nonsynostotic occipital plagiocephaly cohort was breast-fed less than the general population, demonstrating that breast-feeding may be preventative, as breast-fed infants are repositioned more frequently and sleep for shorter periods. As in other studies, cranial molding helmet therapy was more effective in correcting nonsynostotic occipital plagiocephaly than repositioning alone.