Positional plagiocephaly

Positional plagiocephaly: results of the osteopathic treatment of 424 infants. An observational retrospective cohort study

BACKGROUND

Positional plagiocephaly is an asymmetrical flattened skull deformity whose incidence increased significantly in the last decades. Osteopathic treatment has been suggested to tackle early deformational sequences, in order to ensure the correct development of the child. The aim of the study was to assess the effectiveness of osteopathic treatment of positional cranial deformities in infants.

METHODS

Retrospective observational study carried out at the Section of Neonatology and Neonatal Intensive Care Unit of the Department of Interdisciplinary Medicine of University of Bari, Italy in collaboration with a specialized pediatric osteopath.

RESULTS

424 infants were enrolled. Isolated positional plagiocephaly affected the vast majority of infants (n. 390, 91.98%); 34 patients (8.02%) were diagnosed with positional brachycephaly. Both infant groups (positional plagiocephaly and positional brachycephaly) had a median severity score of 3 (IQR: 3 - 3 and 2 - 3, respectively) and benefited from a median of 3 osteopathic sessions (IQR 3-4 and 2-4, respectively). Higher severity scores of positional asymmetries were significantly more common in preterm neonates (Pearson chi2: 11.58; p-value: 0.021) and in males (Pearson chi2: 10.06; p-value: 0.039).

CONCLUSIONS

Significant improvements in positional cranial deformations of children were obtained after only five osteopathic treatments provided in the first months of life. The osteopathic treatment could positively impact the clinical history of patients with positional plagiocephaly and positional brachycephaly.

IMPLICATION FOR PRACTICE

• Positional plagiocephaly is increasingly common among infants and may cause moderate to severe neurodevelopmental adverse effects. • Osteopathic treatment may tackle early deformational sequences, in order to ensure the correct development of the child. • Our study reveals that cranial asymmetry of infants with positional plagiocephaly is significantly reduced after only five osteopathic treatments provided in the first months of life. • Osteopathic treatment should be offered as a first line approach to young infants diagnosed with positional plagiocephaly.

Parental Education for the Prevention of Plagiocephaly

INTRODUCTION

The American Academy of Pediatrics Back-to-Sleep Campaign significantly reduced infant mortality from sudden infant death syndrome. As a result of prolonged supine positioning, the incidence of deformational plagiocephaly has also risen 5-fold since its adoption. We aimed to improve the current educational paradigm for new parents with the goal of reducing the incidence of plagiocephaly within the confines of the Back-to-Sleep Campaign. We hypothesized that the early addition of plagiocephaly focused education for parents would reduce cephalic index, the ratio of head width to length, used as an easily measured objective proxy for positional plagiocephaly.

METHODS

Children were screened at their newborn visit. Premature newborns and those diagnosed with craniofacial disorders were excluded. For those enrolled, biparietal and anteroposterior measurements of the head were obtained using manual calipers to obtain cephalic index. Subjects randomly assigned to the intervention group were shown a 2-minute video and given an educational pamphlet on methods to prevent plagiocephaly. Unpaired 2-sample t tests comparing mean differences in intervention and control were performed.

RESULTS

Thirty-nine subjects were enrolled as of November 2023 with variable lengths of follow-up completed. The average baseline cephalic index for subjects in the control group was 82.7 and 83.8 for intervention group. Unpaired 2-sample t tests were performed at 2-, 4-, and 6-month time points to analyze the difference between groups. At 4 months, average cephalic index for subjects in the control and treatment group, respectively, was 90.6 and 83.4 (P = 0.02).

SIGNIFICANCE

Parental education at the newborn visit led to decreases in cephalic index, a proxy for positional plagiocephaly, compared with control patients. This simple intervention has the potential to reduce parental stress and healthcare costs associated with the evaluation and treatment of plagiocephaly.

Practical Review of the Cost of Diagnosis and Management of Positional Plagiocephaly

Positional plagiocephaly has garnered increased research interest since the introduction of the Back to Sleep campaign in the 1990s, and the subsequent increase in infants with cranial deformity. Research has focused on treatment outcomes and developing new modalities to address asymmetric heads. Little attention has been given to the cost of treatment and diagnosis. This study aimed to summarize the literature and provide an overview of the costs associated with a diagnosis of positional plagiocephaly.

METHODS

A literature review was performed by searching PubMed and Ovid Embase to identify studies pertaining to the "cost" of plagiocephaly diagnosis or treatment through direct financial factors, disturbance to daily routines (ie, through treatment prolongation), or related stress.

RESULTS

Twenty-nine peer-reviewed studies were included. Treatment options for plagiocephaly are stratified by severity and age of diagnosis, with different pathways available to treat different stages of asymmetry. The common factor across all treatment modalities is that earlier diagnosis unequivocally leads to better aesthetic outcomes and shorter treatment times. This leads to lower costs for treatment, a lower stress burden for parents, and lower costs for the healthcare system in the future through reduction of long-term effects. Our theoretical cost model suggests that early diagnosis at 4 months can lead to a treatment cost of $1495, when compared with $5195 for detection of deformity at or after 6 months.

CONCLUSION

The dramatic cost disparity between early and late diagnosis highlights the need for reliable methods to accurately detect cranial deformity early in an infant's life.

Where Are We Headed? Diagnosing Abnormal Head Shapes Through Virtual Care Visits

PURPOSE

Since the beginning of the coronavirus disease 2019 pandemic in early March, there has been a push to expand virtual patient care visits instead of in-person clinic visits. Studies have found that telemedicine can provide efficient triaging, reduction in emergency room visits, and conservation of health care resources and personnel. Although virtual patient care has been implicated in providing similar outcomes to traditional face-to-face care in patients affected with coronavirus disease 2019, there are a lack of studies on the effectiveness of virtual care visits (VCVs) for patients with craniosynostosis or deformational plagiocephaly. This study aims to develop an understanding of whether physicians can accurately diagnose pediatric patients with craniosynostosis or deformational plagiocephaly via VCVs, and whether they can determine if affected patients will benefit from helmet correction or if surgical treatment is required.

METHODS

An Institutional Review Board-approved retrospective chart analysis over a 4-month period (March 1, 2020 to June 30, 2020) was performed analyzing all pediatric patients (<18 years old) who underwent virtual care calls for diagnosis and treatment of abnormal head shape. Patients were referred to UT Physicians Pediatric Surgery clinic for evaluation by a member of the Texas Cleft-Craniofacial Team (2 surgeons or 1 physician's assistant). Variables such as patient demographics, diagnosis, and need for confirmation were pulled and recorded from Allscripts Electronic Medical Records software.

RESULTS

Thirty-five patients were identified who fit our search criteria. Out of these patients, eleven (31.43%) cases were diagnosed with craniosynostosis, twenty-two (62.86%) cases were diagnosed with deformational plagiocephaly, and 2 (5.71%) cases were diagnosed as being normocephalic. Median age at virtual care evaluation was 14.10 months (Interquartile Range [IQR] 5.729, 27.542) for patients diagnosed with craniosynostosis and 6.51 months (IQR 4.669, 7.068) for patients diagnosed with deformational plagiocephaly. All eleven (100%) patients diagnosed with craniosynostosis were referred for a confirmatory computed tomography scan before undergoing surgical intervention and saw an alleviation in head shape postoperatively. Eighteen (81.82%) of patients diagnosed with deformational plagiocephaly were recommended to undergo conservative treatment and the remaining 4 (18.18%) were recommended for helmet therapy. Two cases were unable to be diagnosed virtually. These patients needed a follow-up visit in person to establish a diagnosis and plan of treatment.

CONCLUSIONS

Virtual care visits are increasing in frequency and this includes consultations for abnormal head shapes. Our experience demonstrates that the majority of patients can be evaluated safely in this modality, with only 5.71% requiring additional imaging or in-person visits to confirm the diagnosis. Our study underscores the feasibility of virtually diagnosing and recommending a plan for treatment in pediatric patients with abnormal head shapes. This information can be implemented to further our knowledge on the accuracy of diagnosis and treatment options for patients with craniosynostosis and deformational plagiocephaly. Further analyses are needed to quantify the financial and patient-reported outcomes of VCVs for these patients.

Infant Cranial Deformity: Cranial Helmet Therapy or Physiotherapy?

Objective: To compare cranial helmet therapy (CHT) and physiotherapy (PT) for the effective treatment of positional plagiocephaly in infants in terms of improving functional recovery. Methods: This was a prospective cohort study involving 48 infants between 5–10 months of age with cranial deformities. The Cranial Vault Asymmetry Index (CVAI) and the Brunet–Lezine scale were calculated at the initiation of the study and after 40 treatment sessions. Results: The infants’ first assessment showed a delay in overall development areas with a global developmental quotient (DQ) (posture, coordination, sociability, and language) of 80.15. Although developmental improvements were observed in both groups in the Brunet–Lezine scale after treatment, the MANCOVA test showed no significant differences (F(5) = 0.82, p = 0.506, eta² = 0.09). The CVAI reduced to 4.07% during the final evaluation in the cranial helmet group and 5.85% in the physiotherapy group without any significant differences between the two therapies (p = 0.70). Conclusions: No statistically significant differences were found between CHT and PT. After treatment, improvements from baseline measurements were observed in each of the readings of cranial deformity.

Exploring the Relationship between Maternal Health Literacy, Parenting Self-Efficacy, and Early Parenting Practices among Low-Income Mothers with Infants

OBJECTIVE

To explore the association of maternal health literacy (MHL), parenting self-efficacy and early parenting practices among low-income mothers with infants.

DESIGN

A cross-sectional, descriptive correlational design.

PARTICIPANTS

Low-income mothers (N=186) with infants.

METHODS

Face-to-face interviews were conducted using English and Spanish versions of questionnaires by trained bilingual research assistants. The Newest Vital Sign (NVS) screening tool was used to measure MHL.

RESULTS

Nearly three-quarters (72%) of mothers were rated as having low MHL. In the bivariate analysis, MHL was positively correlated with education, household income, language, social support, parenting self-efficacy, and early parenting practices, but negatively correlated with number of children. The study findings demonstrate that parenting self-efficacy had a mediating effect on MHL and early parenting practices among mothers with infants.

CONCLUSION

Results suggest that future research is needed to advance MHL in low-income mothers and to inform potential HL interventions for this target population.

Relevé postnatal Rourke 2017

Objectif

Décrire le processus et les données probantes ayant servi à mettre à jour les recommandations en matière de soins préventifs du RPR 2017 afin d’aider les professionnels de soins de première ligne à prendre les décisions sur les manœuvres à prioriser et à mettre en application dans la pratique.

Qualité des données

Nous avons effectué une recherche des publications médicales entre juin 2013 et juin 2016 en ayant recours à la méthodologie GRADE (Grading of Recommendations Assessment, Development and Evaluation) pour évaluer rigoureusement les principales études de recherche, et en présence d’un appui substantiel dans les nouvelles publications, nous avons modifié les recommandations.

Message principal

Les changements importants des recommandations en matière de soins préventifs pour les enfants de 5 ans et moins sont l’ajout de la surveillance de l’indice de masse corporelle à compter de 2 ans; des données probantes plus robustes étayant l’introduction d’aliments allergènes sans délai (changement de la qualité de la recommandation de passable à bonne); la recommandation de poser aux parents des questions validées sur les effets de la pauvreté, des données probantes montrant qu’il n’existe aucun niveau sécuritaire d’exposition des enfants au plomb; une recommandation en matière de durée quotidienne du sommeil; la qualité de la recommandation est passée de passable à bonne pour les éléments liés à la prévention et au dépistage des expériences défavorables durant l’enfance, y compris l’évaluation des ecchymoses chez les bébés de moins de 9 mois; et la surveillance de la tension artérielle exclusivement chez les enfants à risque.

Conclusion

Les expositions et les habitudes durant la petite enfance ont des conséquences sur la santé à court et à long terme. Le RPR continue de publier des mises à jour pour veiller à ce que les professionnels de la santé soient équipés pour favoriser la santé et le bien-être tout au long de la vie par l’entremise de soins éclairés par des données probantes aux jeunes enfants.

Rourke Baby Record 2017: Clinical update for preventive care of children up to 5 years of age

OBJECTIVE

To describe the process and evidence used to update preventive care recommendations in the 2017 Rourke Baby Record to assist primary care providers' decisions around which maneuvers to prioritize and implement in practice.

QUALITY OF EVIDENCE

A search of the literature from June 2013 to June 2016 was conducted, using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodology to critically appraise primary research studies, and recommendations were changed where there was substantial support from the new literature.

MAIN MESSAGE

The important changes in preventive care recommendations for children up to 5 years of age include the addition of body mass index monitoring as of 2 years of age; stronger evidence to support the introduction of allergenic foods without delay (strength of recommendation change from fair to good); the recommendation to ask validated questions regarding the effects of poverty; evidence showing no safe level of lead exposure in children; the recommendation of a daily sleep duration; the upgrade of recommendation strength from fair to good of items related to the prevention and detection of adverse childhood experiences, including assessment of bruising in babies younger than 9 months; and blood pressure monitoring only for children at risk.

CONCLUSION

Early childhood exposures and habits have short- and long-term health consequences. The Rourke Baby Record will continue to publish updates to ensure that primary care providers are equipped to promote lifelong health and well-being through evidence-informed care in young children.

Periocular Asymmetry in Infants with Deformational Posterior Plagiocephaly

PURPOSE

To analyze the clinical significance of the periorbital features associated with the facial asymmetry that is common in deformational posterior plagiocephaly (DPP).

PATIENTS AND METHODS

We identified 32 patients with DPP, photographed their faces and tops of their head, and performed a complete eye examination. Four examiners analyzed the patient's periorbital features on the photographs.

RESULTS

Median age was 6.5 months (range 3-12 months). Pseudoptosis was identified in 30 patients and pseudo-brow ptosis in 19. Pseudoptosis was marked in 17 patients. Five patients were misdiagnosed with congenital blepharoptosis and received regular follow-ups for amblyopia checks until the diagnosis of pseudoptosis was established. All patients had normal levator function and symmetric eyelid crease. One patient with pseudoptosis and physiologic anisocoria was diagnosed with pseudo-Horner syndrome after a negative 10% cocaine test. None of the patients developed meridional or occlusion amblyopia.

CONCLUSION

DPP is the most frequent form of skull deformation in infants. Its main features are occipital flatness and facial asymmetry. Infants with DPP may present with pseudoptosis and pseudo-brow ptosis on the contralateral side of the occipital flatness. The pseudoptosis in DPP is non-amblyogenic, therefore, ophthalmologic intervention and regular follow-ups are not necessary unless other abnormalities co-exist.

Facial asymmetry correction with moulded helmet therapy in infants with deformational skull base plagiocephaly

PURPOSE

The recommendation issued by the American Academy of Pediatrics in the early 1990s to position infants on their back during sleep to prevent sudden infant death syndrome (SIDS) has dramatically reduced the number of deaths due to SIDS but has also markedly increased the prevalence of positional skull deformation in infants. Deformation of the base of the skull occurs predominantly in very severe deformational plagiocephaly and is accompanied by facial asymmetry, as well as an altered ear position, called ear shift. Moulded helmet therapy has become an accepted treatment strategy for infants with deformational plagiocephaly. The aim of this study was to determine whether facial asymmetry could be corrected by moulded helmet therapy.

MATERIALS AND METHODS

In this retrospective, single-centre study, we analysed facial asymmetry of 71 infants with severe deformational plagiocephaly with or without deformational brachycephaly who were undergoing moulded helmet therapy between 2009 and 2013. Computer-assisted, three-dimensional, soft-tissue photographic scanning was used to record the head shape before and after moulded helmet therapy. The distance between two landmarks in the midline of the face (i.e., root of the nose and nasal septum) and the right and left tragus were measured on computer-generated indirect and objective 3D photogrammetry images. A quotient was calculated between the two right- and left-sided distances to the midline. Quotients were compared before and after moulded helmet therapy. Infants without any therapy served as a control group.

RESULTS

The median age of the infants before onset of moulded helmet therapy was 5 months (range 3-16 months). The median duration of moulded helmet therapy was 5 months (range 1-16 months). Comparison of the pre- and post-treatment quotients of the left vs. right distances measured between the tragus and root of the nose (n = 71) and nasal septum (n = 71) revealed a significant reduction of the asymmetry (Tragus-Nasion-Line Quotient: 0.045-0.022; p < 0.0001; Tragus-Subnasale-Line Quotient: 0.045-0.021; p < 0.0001). The control group without treatment showed no significant change in the quotient (Tragus-Nasion-Line Quotient no helmet: 0.049-0.055/Tragus-Subnasale-Line Quotient no helmet: 0.039-0.055).

CONCLUSION

Moulded helmet therapy can correct facial symmetry in infants with deformational plagiocephaly and associated facial and basal skull asymmetry.

[Efficacy of sleep position correction for treating infants with positional plagiocephaly]

OBJECTIVE

To investigate the efficacy of 2-month course of sleeping position correction in the treatment of positional plagiocephaly in infants aged <8 months.

METHODS

A total of 73 infants with positional plagiocephaly between January 2015 and June 2016 were divided into treatment group (n=46) and control group (n=27) according to parents' wishes. The treatment group received sleeping position correction, while the control group received sleep curve mattress. The oblique diameters A and B in the two groups were measured and the cranial vault asymmetry (CVA) was calculated before and after treatment. The severity of positional plagiocephaly based on CVA was compared between the two groups before and after treatment. The Gesell Developmental Scale was used to determine the developmental quotients (DQs) in the motor, adaptive, language, and social domains in the two groups before and after treatment.

RESULTS

Before treatment, there were no significant differences in oblique diameters A and B, CVA, and DQs in the four specific domains between the two groups (P>0.05). After 2 months of treatment, the treatment group had a significantly greater oblique diameter B and a significantly smaller CVA than the control group (P<0.05); there were no significant differences in DQs in the four specific domains between the two groups (P>0.05). After treatment, both groups had significant improvements in oblique diameters A and B, CVA, and DQs in the motor and adaptive domains (P<0.01); moreover, the treatment group showed a significant improvement in the DQs in the social domain (P<0.01). There was no significant difference in the severity of positional plagiocephaly between the two groups before and after treatment (P>0.05).

CONCLUSIONS

For infants with positional plagiocephaly, sleeping position correction has better efficacy and is more convenient and economical than the sleep curve mattress, so it holds promise for clinical application.

Time to revisit tummy time: A commentary on plagiocephaly and development

Many centres report receiving more referrals for deformational plagiocephaly since implementation of the Back to Sleep campaign. This commentary combines clinical experience, local quality improvement data and existing literature to highlight three points to help prevent and manage plagiocephaly: (1) communicating 'Back to Sleep, Tummy to Play', (2) the importance of early detection and (3) plagiocephaly as a marker of developmental risk. We recommend: (1) equal emphasis on the messages of Back to Sleep and supervised Tummy to Play, to start this messaging early and reinforce at every opportunity; (2) examination of skull shape and neck range of motion as a routine component of the newborn assessment so that caregivers can implement positioning and handling suggestions immediately and (3) physiotherapy referral for babies who have torticollis, or who show persistent or worsening plagiocephaly despite positioning and handling interventions, for further assessment and management.

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.

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.

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.