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

Period prevalence of positional head deformations and implications for practice in a large tertiary neonatal unit

AIM

To establish the prevalence of positional head deformations (PHDs) within a neonatal unit (NU) setting, and to evaluate the subsequent impact that PHDs have on NU graduates and their families.

METHODS

A prospective audit was conducted over a six-week period within a tertiary NU (Brisbane, Australia). Eligible babies were measured weekly using a craniometer where presence, type and severity of PHD were determined. Univariate analysis was undertaken to establish differences in clinical characteristics between babies with, and without, the presence of PHD. A study-specific survey was completed by a separate set of families returning for outpatient follow-up services who represented similar clinical characteristics and risk factors for PHD.

RESULTS

Fifty-three babies were eligible for inclusion in the audit. PHDs were identified in 66% (n = 35) of the cohort, the most common being scaphocephaly (52.8%, n = 28). Within that, 46% (n = 13) were classed as mild, 25% (n = 7) were moderate and 29% (n = 8) were severe. Moderate correlation (r = 0.55) was found between severity of scaphocephaly, and length of time spent in an isolette. Of the 10 (66% response from 15 families) surveys completed, 80% of respondents perceived that their child's PHD had impacted their life.

CONCLUSIONS

Two-thirds of babies developed a PHD during their neonatal admission. Most families surveyed perceived this condition to have an impact on their lives beyond the confines of the nursery. Further research is needed to identify preventative interventions to decrease the prevalence and severity of this common condition.

Comparison of molding helmet therapy versus natural course in twins with nonsynostotic head deformation

This observational study aims to compare the effectiveness of helmet therapy versus natural course in twin siblings suffering from nonsynostotic head deformations. A retrospective analysis of all twin couples treated with helmet therapy between March 2009 and May 2017 at an orthopedic hospital was conducted. Inclusion criteria were me if only one twin received helmet therapy. The other twin acted as control. A classification for different head shapes was used. A total of 61 twin couples was included. Change in outcome parameters of helmet therapy and natural course differed significantly: cranial vault asymmetry (CVA) -0.66 cm vs. -0.04 cm, cranial vault asymmetry index (CVAI) -5.35% vs. -0.51% (both p < 0.001), cephalic index (CI) -3.10% vs. -1.91% (p = 0.006). Helmet therapy showed a success rate (CI < 90% and CVAI ≤7% or better) of 63.6% vs. 21.1% in children with natural course (p = 0.002). Within the limitations of the study it seems that the results of this retrospective, single-center study confirm that helmet therapy to be a reliable treatment for mild to severe positional head deformation.

Changes in Cranial Shape and Developmental Quotient at 6 Months of Age in Preterm Infants

The purpose of this study was to investigate changes in cranial shape among preterm neonates aged 1-6 months and the relationship between developmental quotient (DQ) and cranial shape at 6 months of age. Preterm infants who were hospitalized in our hospital were prospectively followed for 6 months. The cephalic index (CI) and cranial vault asymmetry index (CVAI) were evaluated at 1 (T1), 3 (T2), and 6 months (T3) of age and compared with those of the full-term infants. The relationship between CI or CVAI and DQ at T3 was analyzed using the Enjoji Scale of Infant Analytical Development. A total of 26 participants born at 34.7 ± 1.9 weeks of gestation were included. The CI increased with age (T1: 77.2%, T2: 82.9%, T3: 85.4%, p < 0.01). The prevalence of dolichocephaly at T3 did not significantly differ from that in full-term infants (15.4% vs. 4.5%, p = 0.08). CVAI did not significantly differ between preterm and full-term infants. The DQ showed no significant correlation with either the CI or CVAI (correlation coefficients: 0.23 for CI, -0.01; CVAI). Dolichocephaly improved over time in preterm infants and no relationship between cranial shape and development was observed in preterm infants at 6 months of age.

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.

A systematic review of improved positions and supporting devices for premature infants in the NICU

Background

In the neonatal intensive care unit, nurses often place premature infants in the supine, prone, and lateral positions. However, these positions do not always meet all the physiological needs of premature infants. Thus, many improved positions and various position-supporting devices have been studied to provide infants with a development-friendly and comfortable environment.

Aim

We aimed to help nurses recognize and understand the various improved positions and devices, and to provide nurses with more options in addressing the needs of preterm infants.

Study design

We searched PubMed, Web of Science, and EMBASE from 2012 to 2022 for studies on position management of preterm infants, and screened the search results according to inclusion and exclusion criteria. Then we extracted data and evaluated the quality of the included studies. Finally, we conducted a qualitative summary of the results.

Results

Twenty-one articles were included in this review. Fourteen were studies about improved positions, including hammock position, facilitated tucking position, ROP position, reverse kangaroo mother care position (R-KMC), and supported diagonal flexion position (SDF). Seven were studies on positioning devices, four on cranial deformity prevention, and three on reformative swaddling. They have a positive impact on sleep and flexion maintenance, in addition, they can prevent head deformity and reduce the pain of premature infants.

Conclusion

The position management of premature infants is diversified. Instead of sticking to a single position placement, nurses should adjust the position according to the unique physiological conditions of infants to reduce sequelae and promote their recovery and growth during long-term hospitalization. There should be more studies on position management with large sample sizes in the future.

Positional Plagiocephaly and Craniosynostosis

Along with the decrease in sudden infant death syndrome due to the successful "Back to Sleep" Campaign, there was a reciprocal increase in cases of positional plagiocephaly (PP). The prevalence of PP significantly rose from approximately 5% to upward of 46% at age 7 months. Consequently, clinicians have seen a surge in the number of patients presenting with head shape abnormalities. Not only does this increase in patient volume pose a logistical problem to clinics, but it also poses a potential risk to patients with craniosynostosis, whose head shape anomalies are similar to a "needle in a haystack" of patients with more common PP. This review explores the causes, risk factors, and treatment options of PP and craniosynostosis, along with the differential of head shape anomalies based on phenotypic presentation. In doing so, we hope to provide pediatric care clinicians with the tools necessary to effectively evaluate and manage patients with head shape abnormalities. [Pediatr Ann. 2023;52(1):e10-e17.].

Physical Therapist Interventions for Infants With Nonsynostotic Positional Head Deformities: A Systematic Review

OBJECTIVE

This study sought to examine the methodological quality and summarize the evidence from clinical trials that examined the effectiveness of physical therapist interventions in the management of nonsynostotic positional head deformities in infants.

METHODS

The following electronic databases were searched: PubMed/MEDLINE, ScienceDirect, CINAHL, Scopus, PEDro, and Web of Science. Two different authors conducted the searches and completed the data extraction. Randomized and non-randomized clinical trials were included. The risk of bias was assessed using the Downs and Black Scale and the Cochrane Collaboration's tool.

RESULTS

Six articles were finally included. The main features of interventions included education to parents about positioning, manual therapy, and motor stimulation. The small sample sizes were not adequately powered and methodological quality showed a high risk of bias, mainly from a lack of blinding and limited external validity.

CONCLUSION

There are indicators that suggest that physical therapist interventions may be useful for infants with nonsynostotic head deformities at improving cranial asymmetries and motor development. However, the validity of such conclusion is limited because most trials included had a high risk of bias. More rigorous research on physical therapy, including randomized controlled trials with larger sample sizes, is required in this area.

IMPACT

The high prevalence and incidence of nonsynostotic positional head deformities in infants calls for the development of effective interventions. Physical therapists have a promising role in the improvement of cranial asymmetry and motor development. The most reported interventions involved educating parents about positioning and manual therapy. Some studies show that changes obtained after physical therapist intervention were comparable with those obtained after helmet therapy.

LAY SUMMARY

Early referral to physical therapy may help to prevent or reduce the severity of nonsynostotic positional head deformities. Education about positioning is important to prevent and improve the asymmetry of the baby's head when there is nonsynostotic positional head deformity. Physical therapist interventions can improve motor development in infants with nonsynostotic positional head deformity who have motor delays.

Effects of continued positioning pillow use until a corrected age of six months on cranial deformation and neurodevelopment in preterm infants: A prospective case-control study

BACKGROUND

Preterm infants have a high risk of cranial deformity resulting from external pressures. Such deformity is associated with delayed neurodevelopment.

AIMS

We aimed to clarify the effects of continuous use of positioning pillows on cranial deformity and neurodevelopment in preterm infants.

METHODS

This prospective case-control study was conducted between November 2018 and August 2019. The continuous use of a pillow was initiated after discharge from the neonatal intensive care unit, up to a corrected age of six months. Preterm infants weighing less than 1800 g without neurological abnormalities were included in the study. Patients were divided into two groups: non-pillow group (NP-group) and pillow group (P-group). The primary outcome was the Bayley Scales of Infant Development III (BSID-III) score. We compared asymmetrical cranial deformity and the BSID-III scores in the two groups at a corrected age of six months using the Fisher's exact test and unpaired t-test, respectively.

RESULTS

There were 19 preterm infants (mean gestational age 32.5 ± 1.9 weeks, birth weight 1461.3 ± 244.7) eligible during the study period. The P-group (n = 11) showed asymmetrical cranial deformity at six months less frequently than the NP-group (n = 8) (p = 0.001, Fisher's exact test). Infants in the P-group had significantly higher scores on the BSID-III cognitive scales (95.0 ± 8.4 vs. 86.9 ± 2.6; p = 0.02, unpaired t-test) and fine motor scores on the motor scales (8.6 ± 2.2 vs. 6.6 ± 0.7, p = 0.02, unpaired t-test).

CONCLUSIONS

Continuous pillow use in preterm infants is effective in reducing cranial deformity and improved cognitive and fine motor skills.

TRIAL REGISTRATION

UMIN Clinical Trials Registry, trial no. UMIN000034400 (http://www.umin.ac.jp/ctr/index.htm).

Effect of helmet therapy in the treatment of positional head deformity

AIM

Most positional head deformities can be treated conservatively with postural correction training or a head orthosis ('helmet'). We aimed to investigate whether infants with helmet therapy have cosmetic improvement in head deformity.

METHODS

A total of 376 infants at age 2-40 months who were diagnosed with mild-moderate-severe positional head deformity were enrolled. Among these infants, 101 infants were treated with helmet therapy or postural correction training. After matching by infant's age and time of therapy, three retrospective cohort studies of 56 infants were conducted for infants with plagiocephaly, brachycephaly and asymmetrical brachycephaly, respectively. The cephalic ratio (CR), radial symmetry index (RSI), cranial vault asymmetry (CVA) and cranial vault asymmetry index (CVAI) were compared between two groups before and after treatment.

RESULTS

Before treatment, no significant differences in CR, RSI, CVA and CVAI between groups were found. After treatment, compared with the postural correction training group, the helmet therapy group had significant improvements in CR, RSI, CVA or CVAI (Plagiocephaly: P_CVA = 0.017, P_CVAI = 0.028; Brachycephaly: P_CR = 0.002; Asymmetrical brachycephaly: P_RSI = 0.002, P_CVA  < 0.001, P_CVAI  < 0.001). Moreover, there was no significant difference in head circumference growth between the groups.

CONCLUSIONS

Helmet therapy may be more effective in the treatment of mild-moderate-severe positional head deformity than postural correction training in infants. And helmet therapy may not hinder head circumference growth.

Positional cranial deformation in children: A plea for the efficacy of the cranial helmet in children

BACKGROUND

Cranial deformations have historically aroused the interest of people worldwide. One of the more debated points about positional plagiocephaly is the choice of the treatment. In this article, the senior author (CM) shares his experience on almost 30 years of use of the helmet molding therapy in children with deformation plagiocephaly.

METHODS AND POPULATION

We retrospectively and systematically reviewed the cases of 2188 patients (75% males and 25% females) presenting positional head deformity and treated between 1991 and 2013 with a cranial helmet. To assess the effectiveness of the helmet, we compared the cranial index in bilateral plagiocephaly and the Cranial Diagonals Difference (CDD) in unilateral plagiocephaly at the beginning and at the end of the treatment.

RESULTS

The cranial indexes ranged between 94.4% and 124.2% before the treatment and decreased significantly between 86.8% and 121.4% after the treatment (P<0.01). The CDD ranged between 0.3 cm and 4.5 cm with an average of 1.50±0.54 cm before the treatment and decreased significantly between 0.1 cm and 2.5 cm with an average of 0.72±0.37 cm after the treatment (P<0.01). For unilateral plagiocephaly, at the beginning of the treatment, 2.5% children presented a mild plagiocephaly, 19.6% a moderate plagiocephaly and 77.9% a severe plagiocephaly. At the end of the treatment, the deformation was classified as mild in 40.2% children, moderate in 44.3% children and severe in 15.5% children with significantly less children in the most severe subgroups (P<0.01) Facial symmetry pre-existed before the treatment in 13.7% of children. This rate was significantly increased at the end of the treatment to 66.7% (P<0.01). In only 8 cases (0.2%), the helmet therapy did not allow to obtain correct clinical results and a surgical posterior cranial remodeling was performed.

CONCLUSIONS

The results observed in this series confirms that cranial helmet is a simple and well tolerated alternative which bring satisfying results. Its success implies a good collaboration with parents and a management both by orthoptist, physiotherapist and doctor. Nevertheless, it remains many controversies in the literature concerning in particular long-term cosmetic and functional outcomes. A long-term multicentric prospective study could enable to remove doubts.

Outcome analysis of molding helmet therapy using a classification for differentiation between plagiocephaly, brachycephaly and combination of both

PURPOSE

The incidence of positional head deformation has increased during the last decades. Helmet therapy has been proved to be a reliable method for the treatment of nonsynostotic skull deformities. Until today, a simple classification to differentiate between different head shapes has not been established.

MATERIALS AND METHODS

We suggest a classification system to group patients with plagiocephaly, brachycephaly, and a combination of both, using two simple values: cranial vault asymmetry (CVA), and cephalic index (CI). We further analyzed a study population of 1050 children treated with molding helmets to identify prognostic variables for better outcome within our proposed classification.

RESULTS

In all, 736 patients were male (70.10%) and 314 patients were female (29.90%). Mean improvement of cranial vault asymmetry index (CVAI) ranged from 2.94% to 7.08% (CVA 0.37 cm-0.86 cm) in subgroups of patients defined by classification and severity of deformation. In patients with brachycephaly, CI improved from 4.17% to 8.22%. Duration of therapy differed from 21 weeks to 24 weeks. Children aged 6 months or less showed greater improvement and shorter duration of therapy compared to older patients. In addition to early onset of therapy, classification and severity of deformation were significantly associated with a reduction of the deformation under therapy. There were distinct differences in outcomes between different head shapes.

CONCLUSION

Helmet therapy should be initiated early. Our analysis suggests that the proposed classification correctly identifies patients whose deformation is reduced under therapy.

LEVEL OF EVIDENCE

III.

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.

Positional plagiocephaly reduces parental adherence to SIDS Guidelines and inundates the health system

BACKGROUND

This study sought to better understand parent, grandparent and clinician views of prevention, treatment and costs of plagiocephaly.

METHODS

A qualitative study was conducted using focus groups and semi-structured interviews. A grounded theory approach was taken to build theories from the qualitative data collected. A subjectivist epistemological orientation was taken under the paradigm of positivism.

RESULTS

Ninety-one parents, 6 grandparents and 24 clinicians were recruited from the community as well as primary and tertiary care clinics. Plagiocephaly worried most parents because it could permanently affect their child's 'looks' and some thought it would affect a child's development. Parents were 'willing to do anything' to prevent plagiocephaly including using products or sleeping positions that are contraindicated under sudden infant death syndrome guidelines. Parents found the care pathway convoluted and inconsistent messages were given from different health providers. For clinicians, the high prevalence of flat head is 'clogging up their patient pool', taking up time they used to spend with children with more severe conditions.

CONCLUSION

There is a need to re-emphasize sudden infant death syndrome guidelines for families when they present with an infant with plagiocephaly. Stronger messaging regarding the lack of safety of current pillows marketed to prevent flat head may be useful to decrease their use. Increasing education for all health professionals including general practitioners, allied health and complementary health providers and standardizing assessment and referral criteria may allow the majority of diagnosis and treatment of positional plagiocephaly to occur at points of first contact (e.g. general practitioners, community nurse) and may prevent further burden on the health care system.

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.

Cranial molding helmet therapy and establishment of practical criteria for management in Asian infant positional head deformity

BACKGROUND

The growing number of infants with deformational plagiocephaly (DP) has raised clinical questions about which children, at what age, and how molding helmet therapy (MHT) should be performed especially in Japan.

METHODS

A total of 1,011 Japanese pediatric head deformity infants had undergone MHT after being diagnosed with non-synostotic DP. Three ratios of left to right comparison (anterior, posterior, and overall) were created and analyzed comparing age of starting treatment, helmet wearing period, and severity of skull deformity before with after MHT.

RESULTS

The averages of head symmetry ratios after treatment in all groups (for the occipital region) showed apparent improvement; t(930) = -60.86, p = 0.000. (t(932) = -57.8, p = 0.000.) In the "severe" deformation group, the earlier the treatment was started, the higher symmetry ratio recovery was obtained. Treatment was especially effective when started in 4-month-old infants. In contrast to the "severe" group, the "mild" deformation group showed that MHT was most effective if treatment started before 6 months of age. Again, the earlier the treatment was started, the higher symmetry ratio was achieved, but compared to the "severe" group, it had a modest effect when treatment was started in infants older than 8 months.

CONCLUSION

This is the first large-scale molding helmet study reporting the method and efficacy in Japanese infants. It demonstrated that despite the structural and physiological differences from infants of other races, molding helmet therapy is effective in Asian-born infants, provided that intervention timing and recognition conditions are met.

Prevalence of head deformities in preterm infants at term equivalent age

INTRODUCTION

Due to a rising number of head deformities in healthy newborns, there has been an increasing interest in nonsynostotic head deformities in children over recent years. Although preterm infants are more likely to have anomalous head shapes than term newborns, there is limited data available on early prevalence of head deformities in preterm infants.

AIMS

The purposes of the present study were to acquire quantitative data on head shape of preterm infants at Term Equivalent Age (TEA), to determine the prevalence of symmetrical and asymmetrical head deformities and to identify possible risk factors.

METHODS

In a cross-sectional study design, Cranial Vault Asymmetry Index (CVAI) and Cranial Index (CI) calculated from routine head-scans with a non-invasive laser shape digitizer were recorded and categorized in type and severity of deformation for three different groups of gestational age. Perinatal and postnatal patient data was tested for possible associations.

RESULTS

Scans of 195 infants were included in the study. CVAI at TEA was higher in very preterm (4.1%) compared to term and late preterm infants. Prevalence of deformational plagiocephaly was 38% in very preterm infants. CI was lower in very (71.4%) and late (77.2%) preterm infants compared to term infants (80.0%). Compared to term babies (11%), a large number of very (73%) and late (28%) preterm infants exhibited dolichocephaly at TEA.

DISCUSSION

Prevalence of symmetrical and asymmetrical head deformities in preterm infants is high at TEA. Interventions are required to prevent head deformities in preterm infants during the initial hospital stay.