Neurodevelopmental implications of "deformational" plagiocephaly

Effects of osteopathic manipulative treatment on children with plagiocephaly in the context of current pediatric practice: a retrospective chart review study

CONTEXT

Deformational plagiocephaly (DP) is on the rise in pediatric patients. The current standard of care recommended for management is repositioning with possible addition of cranial orthoses. However, strong data are lacking to support these recommendations. Osteopathic manipulative treatment (OMT) is another treatment option for DP that is also lacking evidential support.

OBJECTIVES

This retrospective chart review study investigated the effects of OMT at restoring a more symmetrical cranial bone configuration in children with DP.

METHODS

A retrospective chart review was performed on medical records of patients with a diagnosis of DP from three private practices over a 4-year period from September 2017 to December 2021. Inclusion criteria were diagnoses of DP by a referring physician and aged 10 months or less at the time of initial evaluation and treatment. Patients were excluded if they had confounding diagnoses such as genetic syndromes or severe torticollis. A total of 26 patients met these criteria, and their records were reviewed. The main outcome reviewed was anthropometric assessment of the cranium, mainly the cranial vault asymmetry index (CVAI).

RESULTS

Participants demonstrated a mean CVAI - a measure that determines the severity of DP - of 6.809 (±3.335) (Grade 3 severity) at baseline, in contrast to 3.834 (±2.842) (Grade 2 severity) after a series of OMT treatments. CVAI assessment after OMT reveals statistically significant (p≤0.001) decreases in measurements of skull asymmetry and occipital flattening. No adverse events were reported throughout the study period.

CONCLUSIONS

The application of OMT has shown potential benefit for reducing cranial deformity in patients with DP.

Factors in Infancy That May Predict Autism Spectrum Disorder

The global increase in the prevalence of ASD (Autism Spectrum Disorder) is of great medical importance, but the reasons for this increase are still unknown. This study sought to identify possible early contributing factors in children who were later diagnosed with ASD. In this retrospective cohort study, postnatal records of 1105 children diagnosed with ASD were analyzed to determine if any signs of ASD could be found in a large database of births and well-baby care programs. We compared the recordings of typically developing children and analyzed the differences statistically. Rapid increases in weight, height, and head circumference during early infancy predict the development of ASD. In addition, low birth weight, older maternal age, and increased weight and height percentiles at six months of age together predict the development of ASD. At two years of age, these four parameters, in addition to impaired motor development, can also predict the development of ASD. These results suggest that the recent increase in ASD prevalence is associated with the "obesity epidemic" and with recommendations of supine sleeping to prevent Sudden Infant Death Syndrome, associated with atypical neural network development in the brain.

Ultrasonography as first line imaging for the diagnosis of positional plagiocephaly

BACKGROUND

In the last years, numerous studies evaluated different tools for the diagnosis of positional plagiocephaly (PP). The purpose of this study was to evaluate ultrasonography (US) as a first line screening test of lambdoid sutural patency in child with PP and to compare our results with the literature.

METHODS

All consecutive patients who referred to our Institute from January 2016 to October 2017 with the suspicion of PP, were included in the study and performed US examination of the lambdoid sutures. A 3-6-month clinical follow-up was performed by a pediatric neurosurgeon or a pediatrician to confirm the diagnosis of PP.

RESULTS

Thirty-five children performed US examination and in all cases the diagnosis of PP was confirmed. No cases of anticipated suture fusion were examined during this period. The concordance between US findings and clinical exam follow-up was 100%.

CONCLUSIONS

Ultrasonography of the lambdoid sutures represents an ideal first-line screening test and reliable alternative to other diagnostic techniques for lambdoid sutural patency in child with PP, being radiation free, fast and cheap.

A Randomized Controlled Trial of Osteopathic Manipulative Therapy to Reduce Cranial Asymmetries in Young Infants with Nonsynostotic Plagiocephaly

OBJECTIVE

This study aimed to compare the efficacy of osteopathic manipulative therapy (OMTh) versus light touch therapy (LTT) in reducing cranial asymmetries in infants with nonsynostotic plagiocephaly (NSP).

STUDY DESIGN

A prospective, parallel-group, single-center, LTT-controlled randomized clinical trial was conducted in the Department of Neonatology of Sant'Anna Hospital in Turin, Italy, from September 6, 2016 to February 20, 2020. We enrolled infants of 1 to 6 months of age with NSP, who were then randomly assigned to the study group (repositioning therapy plus six sessions of OMTh) or the control group (repositioning therapy plus six sessions of LTT). The outcome was the reduction of the oblique diameter difference index (ODDI) score <104%, which was assessed at the end of the intervention protocol (at 3 months) and at 1 year of age.

RESULTS

A total of 96 infants were randomized, 48 in the OMTh group and 48 in the LTT group, with mean ages of 3.1 versus 3.2 months, and baseline ODDI score of 110.2 versus 108.7%. In the OMTh group, a significant reduction of the ODDI score <104%, compared with the LTT group, was observed in the intension-to-treat (ITT) and per-protocol (PP) analyses. The ITT analysis revealed an ODDI score <104% in the OMTh group at 3 months (risk difference: 0.41; 95% confidence interval [CI]: 0.25-0.53; p < 0.001) and at the follow-up at 1 year of age (risk difference: 0.47; 95% CI: 0.31-0.64; p < 0.001). The PP analysis at 3 months reported a risk difference of 0.44 (95% CI: 0.27-0.60; p < 0.001), and at 1 year of age, a risk difference of 0.54 (95% CI: 0.36-0.72; p < 0.001).

CONCLUSION

In infants with NSP, a course of six OMTh sessions significantly reduced cranial asymmetries at both the 3-month and 1-year follow-up assessments, compared with LTT. This study is registered with ClinicalTrial.gov (identifier: NCT03970395; www.

CLINICALTRIALS

gov ).

KEY POINTS

· OMTh plus repositioning therapy significantly decreased the risk and severity of NSP compared with LTT.. · OMTh reduced mild and moderate cranial asymmetries.. · The role of OMTh in severe cranial asymmetries should be investigated in a multicenter trial..

Behavioral and Social Functioning of Children With and Without Positional Plagiocephaly: Late Infancy to School Age

Positional plagiocephaly and/or brachycephaly (PPB) is associated with cognition, motor, and other developmental outcomes, but little is known about the social-behavioral adjustment of children with PPB. The primary aim of this study was to compare the social-behavioral development of preschool and school-age children with and without PPB and to examine the potential moderating effects of PPB severity on group differences.

Two hundred twenty children with a history of PPB and 164 controls participated in at least one behavioral assessment at 4-11 months, 18 months, 36 months, and 7 years. The frequencies of observed problem behaviors and social competence were estimated using the Child Behavior Checklist Ages 1.5-5 (CBCL/1.5-5), Caregiver-Teacher Report Form(C-TRF), CBCL/6-18, and Teacher Report Form.

Children with PPB were similar to controls on the internalizing, externalizing, or total problems composites. At 7 years, CBCL/6-18 total competence scores were significantly lower in children with histories of PPB than controls. In analyses stratified by PPB severity, we found that children with moderate/severe PPB had slightly higher scores on the C-TRF internalizing scale at 36 months and lower total competence scores at age 7 years. Children who had a history of mild PPB were similar to controls on all outcomes.

This study is the first to examine social and behavioral outcomes in a large cohort of children with and without a history of PPB. We found limited evidence of an association between PPB and parent and teacher-reported social-emotional and behavioral adjustment through early school-age.

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.

Novel Screening and Monitoring Techniques for Deformational Plagiocephaly: A Systematic Review

This article summarizes the current state of diagnostic modalities for infant craniofacial deformities and highlights capable diagnostic tools available currently to pediatricians.

Skull shape abnormalities in ischemic cerebrovascular and mental diseases in adults

Morphological changes in the child skull due to mechanical and metabolic stimulation and synostosis of the suture are well known. On the other hand, few studies have focused on clinical conditions relevant for adult skull deformity. We retrospectively reviewed computed tomography (CT) findings obtained from 365 cases that were treated for head injuries, moyamoya disease, cervical internal carotid artery stenosis, and mental diseases, and investigated the morphological changes in the skull associated with these diseases. The findings from head injuries were used not only for control subjects, but also for the analysis of generational changes in skull shape based on birth year. Head shape had a brachiocephalic tendency with occipital flattening in people born from the 1950s onwards. Cases of moyamoya disease, cervical internal carotid artery stenosis, and mental diseases showed significantly thicker frontal and occipital bone than those of control subjects. The skull thickening was especially noticeable in the frontal bone in moyamoya disease. Plagiocephaly was significantly frequent in moyamoya disease. These uncommon skull shapes are useful CT findings in screening subjects for early evidence of mental diseases and intracranial ischemic diseases with arterial stenosis.

Diagnosis and Management of Suture-Related Concerns of the Infant Skull

The cranial fontanelles and sutures have several benign variations, including most cases of "early" or "late" closure of the anterior fontanelle, bathrocephaly, overriding sutures, and benign metopic ridging. However, recognizing true craniosynostosis and referring the patient to a craniofacial specialist in a timely fashion are imperative, as minimally invasive options can be offered to most patients younger than 6 months of age. Gaining comfort with the physical examination of an infant with an abnormal head shape is best achieved through experience and pattern recognition and will frequently facilitate an accurate diagnosis without the need for ionizing radiation.

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.

Demographics of Positional Plagiocephaly and Brachycephaly; Risk Factors and Treatment

ABSTRACT

In the last 3 decades, the incidence of positional cranial deformations in infants, such as positional plagiocephaly and positional brachycephaly, has increased. The deviating shape often causes parental concern for the later psychosocial wellbeing of the child. Treatment options are nonoperative, varying from positional change to helmet therapy, of which the effect has often been debated. Multiple risk factors have been associated with an increased risk on the development of these deformations. The goal of this study was to assess the impact of known risk factors on the type and severity of resulting positional cranial deformation.Parents were asked to fill out a questionnaire regarding the presence of risk factors, such as gender, age, pregnancy duration, method of delivery and reasons for atypical deliveries, breech position, birth weight, developmental status, positional preference, family history, number of siblings, and torticollis presence. Treatment methods were documented and plagiocephalometry was used to measure the cranial proportions. All children were invited to participate in short-term follow-up. The significance of the risk factors and the effect of different kinds of therapy are discussed. Although no significant correlation was found between severity and risk factors, some risk factors could be correlated with the kind of positional cranial deformation. Of the different therapies, helmet therapy had a significant impact on the reduction of positional plagiocephaly.

Association of Gestational Opioid Exposure and Risk of Major and Minor Congenital Malformations

IMPORTANCE

The rapid increase of opioid-related overdoses and deaths has become a public health concern in the US. Use of prescription opioids in pregnant women has increased; results from teratogenicity studies remain controversial.

OBJECTIVE

To evaluate the association between maternal prescription opioid use (excluding opioid use disorders) during pregnancy and the incidence of congenital malformations.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective population-based cohort study evaluated linked Rhode Island Medicaid claims and vital statistics data of live births from January 1, 2008, to December 31, 2016. Data analysis was conducted from May 1, 2019, to May 31, 2020. Women who had a live birth during the study period, but no cancer or opioid use disorder, were followed up from 3 months before pregnancy to the end of pregnancy.

EXPOSURES

Data on the mother's prescription opioid exposure were obtained through pharmacy claims and exposure was defined as dispensing of at least 1 prescription opioid during the first, second, or third trimester.

MAIN OUTCOMES AND MEASURES

The primary outcome was overall major or minor congenital malformations, defined as 1 or more major or minor congenital malformation. Secondary outcomes were defined as 10 specific categories of congenital malformations classified by organ systems using International Classification of Diseases diagnosis codes.

RESULTS

Of 12 424 included pregnancies, 891 mothers (7.2%) received prescription opioids during pregnancy and 3153 infants (25.4%) were diagnosed with major or minor congenital malformations. Comparing prescription opioid exposure vs nonexposure, no excess risk was observed for major birth defects in infants with opioid exposure in trimester 1 (adjusted relative risk [aRR], 1.40; 95% CI, 0.84-2.34), and higher risks were found for overall minor birth defects in trimester 3 (aRR, 1.26; 95% CI, 1.04-1.53) and minor birth defects in the musculoskeletal system in trimester 2 (aRR, 1.50; 95% CI, 1.10-2.03) and trimester 3 (aRR, 1.65; 95% CI, 1.23-2.22). Significant dose responses in selected minor malformations and effects of specific opioids were also identified. Hydrocodone in trimester 2 (aRR, 3.01; 95% CI, 1.80-5.03) and oxycodone in trimester 3 (aRR, 2.43; 95% CI, 1.37-4.02) were associated with plagiocephaly, polydactyly, and other specified congenital deformities of the hip.

CONCLUSIONS AND RELEVANCE

The findings of this study suggest a higher risk of minor congenital malformations associated with use of prenatal prescription opioids in trimester 3, which seems to be dose-dependent. Further investigation is needed to establish causality and explore the physiologic plausibility of the association.

Toward quantitative assessment of deformational plagiocephaly and brachycephaly at the point-of-care

Purpose: Develop and validate algorithms that can enable a novice user to quantitatively measure the head shape parameters associated with deformational plagiocephaly and brachycephaly (DPB) using 2D rendered images. Approach: First, the head contour is extracted semi-automatically using the intelligent scissors method. We then automatically compute two indices used in the clinical determination of the DPB from the head shape parameters: the cranial index (CI) and the cranial vault asymmetry index (CVAI). We also present methods to quantify and compensate for the user variability, including camera angle and distance from the head using 2D rendered images. We compared the results of our technology with ground-truth (GT) measurements from 53 infants with DPB and normal cranial parameters. Results: The Spearman correlation coefficient between the new 2D rendered method and the 3D GT was 0.94 ( p < 0.001 ) and 0.96 ( p < 0.001 ) for CI and CVAI, respectively. Different simulated camera angles and distances from the head resulted in variation in CI and CVAI in the range of [ - 2.0 , 6.0 ] and [ - 4.0 , 4.0 ] units, respectively. The limits of agreement of the Bland-Altman test were reduced from [ - 3.6 , 5.3 ] and [ - 3.6 , 4.2 ] to [ - 0.5 , 3.0 ] and [ - 1.3 , 1.6 ] for CI and CVAI, respectively, by combining results from different camera angles and positions in our method. The overall accuracy of the proposed technology for DPB detection was 100%. Conclusions: The 2D rendered images of the head can be accurately analyzed to assess DPB. Further study on 2D photos taken from human subjects is warranted.

Nonsynostotic Plagiocephaly: Prevention Strategies in Child Health Care

The dissertation, comprising a clinical intervention and three supporting studies, aimed to assess if it is possible to prevent nonsynostotic plagiocephaly while promoting safe infant sleeping practices. Five individuals were trained to assess cranial asymmetry and then reliability-tested; the interpreted results indicate substantial strength of rater-agreement. Intervention participants were allocated to group. Only intervention group nurses participated in the continuing education on plagiocephaly developed for nurses. A survey compared information intervention and control group parents received from nurses; intervention group parents were significantly more aware of recommendations than the controls. Nurse education was evaluated by asking intervention and control group nurses and parents two open-ended questions; the intervention group reported new re-positioning strategies. The effect of the intervention on cranial shape was evaluated by assessing asymmetry at 2, 4, and 12 months (176 intervention group; 92 controls). It was nine times more common that cranial asymmetry at two months reversed by four months when parents were aware of written recommendations from their nurse (OR = 9.09 [0.02; 0.48], p = 0.004) when adjusted for group. An infant’s risk of asymmetry persisting until 12 months was significantly reduced in the intervention group (RR = 0.35 [0.13; 0.94], p = 0.03). Preventing brachycephaly was difficult. Conclusions: the assessors were considered reliable; educating nurses promoted the integration of new recommendations in practice; the intervention was associated with early reversal of nonsynostotic plagiocephaly.

Positional plagiocephaly from structure to function: Clinical experience of the service of pediatric osteopathy in Italy

OBJECTIVE

Aim of the study is to evaluate disorders related to positional plagiocephaly and introduce a new model of early intervention based on the osteopathic integrated approach.

METHODS

We review clinical experience of the "Program for Neurodevelopmental Follow-up and Pediatric Osteopathy", a service dedicated to newborns at risk for developmental disorders.

RESULTS

We present clinical data of 310 newborns followed during first years of life. Data analysis examines perinatal history, general features and disorders that could be related to plagiocephaly.

CONCLUSIONS

The experience confirms that plagiocephaly is not only a problem regarding the shape of the head, it involves the functions. In our Service most babies (81%) with positional plagiocephaly showed isolated or associated disorders that had an impact on growth, behavior and development. The early intervention based on the osteopathic integrated approach is addressed not only to the cranial shape but consider the baby as a whole, and the environment where he lives.

Prevailing head position to one side in early infancy-A population-based study

AIM

To determine the prevalence of prevailing head position to one side (PHP) in young infants and to evaluate its associations with reaching performance, neurological condition and perinatal and socio-economic factors.

METHODS

Observational study in 500 infants (273 boys) 2-6 months corrected age, representative of the Dutch population (median gestational age 39.7 weeks (27-42); birthweight 3438 g (1120-4950). Prevailing head position to one side and reaching performance were assessed with the Infant Motor Profile; neurological condition with the Standardized Infant NeuroDevelopmental Assessment. Socio-economic information and perinatal information were obtained by questionnaire and medical records. Associations were analysed with uni- and multivariable statistics.

RESULTS

Prevailing head position to one side was observed in 100 infants (20%), and its prevalence decreased from 49% at 2 months to 0% at 6 months. Only in infants aged 4-5 months PHP was significantly associated with worse reaching and an at-risk neurological score. Prevailing head position to one side was weakly associated with prenatal substance exposure, post-natal admission to a paediatric ward and paternal native Dutch background.

CONCLUSION

Prevailing head position to one side at 2-3 months is a frequently occurring sign with limited clinical significance. Yet, PHP at 4-5 months is associated with a worse functional and neurological condition. Therefore, PHP at 4-5 months could serve as a red flag indicating possible challenges in later development.

Subjective perception of craniofacial growth asymmetries in patients with deformational plagiocephaly

Objectives

The present investigation aimed to evaluate the subjective perception of deformational cranial asymmetries by different observer groups and to compare these subjective perceptions with objective parameters.

Materials and methods

The 3D datasets of ten infants with different severities of deformational plagiocephaly (DP) were presented to 203 observers, who had been subdivided into five different groups (specialists, pediatricians, medical doctors (not pediatricians), parents of infants with DP, and laypersons). The observers rated their subjective perception of the infants’ cranial asymmetries using a 4-point Likert-type scale. The ratings from the observer groups were compared with one another using a multilevel modelling linear regression analysis and were correlated with four commonly used parameters to objectively quantify the cranial asymmetries.

Results

No significant differences were found between the ratings of the specialists and those of the parents of infants with DP, but both groups provided significantly more asymmetric ratings than did pediatricians, medical doctors, or laypersons. Moreover, the subjective perception of cranial asymmetries correlated significantly with commonly used parameters for objectively quantifying cranial asymmetries.

Conclusions

Our results demonstrate that different observer groups perceive the severity of cranial asymmetries differently. Pediatricians’ more moderate perception of cranial asymmetries may reduce the likelihood of parents to seek therapeutic interventions for their infants. Moreover, we identified some objective symmetry-related parameters that correlated strongly with the observers’ subjective perceptions.

Clinical relevance

Knowledge about these findings is important for clinicians when educating parents of infants with DP about the deformity.

Diagnosis, Management, and Outcome in 9 Children with Unilateral Posterior Synostotic Plagiocephaly

BACKGROUND

Posterior synostotic plagiocephaly represents a rare challenging type of craniosynostosis, often misdiagnosed as a simple posterior positional plagiocephaly. Underdiagnosed forms may result in delayed diagnosis and neurosurgical management, with potential ophthalmologic, cognitive, and aesthetic sequelae in children.

METHODS

Here we retrospectively analyzed data of 9 posterior synostotic plagiocephaly infants treated in our center over a 10-year period (January 2000-December 2009).

RESULTS

Patients averaged 10 months of age, and there was a clear male predominance (8 males/1 female). Cerebral computed tomography scan was performed in all patients, and the abnormal suture was located at the right side in 7 cases (77.77%). Ipsilateral occipitomastoid bulge and occipital flattening were found in all cases (100%). Posterior ear displacement was found in 7 cases (77.77%), and there was minimal facial asymmetry in 4 cases (44.44%). The ophthalmoscopic examination found a papillary edema grade 1 in 2 cases and grade 2 in 4 cases. There were no deaths or reoperation in our series. All of our patients underwent a neurosurgical correction, with total ophthalmic recovery in all patients with preoperative papillae edema. Eight patients had an early satisfactory aesthetic aspect. Long-term follow-up in treated children found a normal childhood, with no major school dysfunctions and normal social integration.

CONCLUSIONS

Interesting findings in our series were male gender predominance and predilection of the right-side synostotic lambdoid suture. We think that early correct diagnosis and appropriate neurosurgical treatment may prevent potential complications such as neurocognitive and aesthetic sequelae in children with posterior synostotic plagiocephaly.

Outcome Analysis of the Effects of Helmet Therapy in Infants with Brachycephaly

Brachycephaly has several potential deleterious effects, including malocclusion, sleep apnea, and abnormal posture. Nevertheless, the research regarding helmet therapy as a treatment strategy for brachycephaly is limited. Herein, we aimed to analyze the factors influencing the effects of helmet therapy in infants with brachycephaly. We retrospectively reviewed the records of 207 infants aged 3–14 months with a cranial index (CI) >90% who received helmet therapy between May 2016 and October 2019 and complied with the treatment protocol well. We used a multiple regression analysis to determine which factors affected the duration of therapy and a Jonckheere–Terpstra test to establish differences in the duration of helmet therapy according to age and severity. We identified brachycephaly severity (p < 0.001), asymmetry (p < 0.001), and age (p < 0.001) as factors affecting the duration of therapy. Helmet therapy might be effective for infants with moderate to severe brachycephaly, assuming good protocol compliance. In addition, younger treatment initiation age and less severe and less asymmetric brachycephaly significantly shorten the treatment duration.

Prediction of school-age IQ, academic achievement, and motor skills in children with positional plagiocephaly

Introduction

Children with positional plagiocephaly and/or brachycephaly (PPB) are at risk of early developmental delay, but little is known about early life factors associated with school-age neurodevelopment. This study examined associations of demographic characteristics, prenatal risk factors and early neurodevelopment assessment with school-age IQ, academic performance, and motor development in children with PPB.

Methods

The study sample consisted of 235 school-age children with PPB followed since infancy. Outcome measures included IQ using the Differential Ability Scales-Second Edition, academic achievement as measured by the Wechsler Individualized Achievement Tests-Third Edition), and motor function using the Bruininks-Oseretsky Test of Motor Proficiency, Second Edition. Linear regression was used to examine the incremental improvement of model fit of demographics, prenatal and early life characteristics, severity of PPB, and neurodevelopment at ages 7, 18, and 36 months as measured by the Bayley-3 on school-age scores.

Results

Mean age at school-age assessment was 9.0 years. Adjusted r² for demographic, prenatal, and early life risk factors ranged from 0.10 to 0.22. Addition of PPB severity and Bayley-3 measures at ages 7 and 18 months did not meaningfully change model fit. Adjusted r² after inclusion of Bayley-3 at 36 months ranged from 0.35 to 0.41.

Conclusion

This study suggests that PPB severity and very early life neurodevelopment have little association with school-age neurodevelopment above and beyond demographic and early life risk factors. However, preschool-age neurodevelopmental assessment may still be useful in identifying children with PPB at risk for delay and who may benefit from early intervention.

The role of age on helmet therapy in deformational plagiocephaly and asymmetric brachycephaly

PURPOSE

This study aimed to investigate the effect of age at helmet therapy onset on treatment efficacy in moderate-to-severe deformational plagiocephaly (DP) and combined DP and asymmetrical brachycephaly (AB) in infants.

METHODS

Ninety-eight infants who were referred to our institution and who underwent helmet therapy between 2014 and 2018 were retrospectively reviewed. Patients with DP [cranial vault asymmetry index (CVAI) > 7% and DD > 10 mm] and AB [CVAI > 7% and cephalic ratio (CR) ≥ 94] were included. Pre- and post-treatment calvarial asymmetries (difference among DD, CVAI, and CR) were measured using 3D screening systems (SmartSoc and Omega Scanner 3D). Infants were classified according to age at treatment onset: group 1 (age, < 6 months) and group 2 (age, ≥ 6 months).

RESULTS

CVAI was statistically different between treatment onset and end in subgroups. Moreover, the regression of CVAI between groups DP1 (- 7.5% ± 1.2%) versus DP2 (- 5.4% ± 1.5%; p = 0.001) and groups AB1 (- 6.6% ± 1.4%) versus AB2 (- 4.4 ± 2.5; p = 0.0013) was statistically significant. CVAI was < 3.5% and CR was ≤ 89 (assumed as normal cranial shape) after treatment in 48%, 40%, 32%, and 6% of infants in groups DP1, DP2, AB1, and AB2, respectively.

CONCLUSION

These findings emphasize the efficacy of helmet therapy for DP and AB. Helmet is an appropriate treatment option particularly for infants with severe DP and AB, and early onset of helmet therapy before the age of 6 months is advised.

Comparing the effects of varied and constant preferred items on improving tummy time for typically developing infants

Tummy time involves placing an infant in a prone position to help build muscle strength. Pediatricians recommend tummy time because it helps with infant development related to milestones such as crawling, rolling over, and sitting up. However, parents sometimes avoid tummy time due to whining or crying when the infant is placed in the prone position. The current study compared two interventions incorporating preferred leisure items (i.e., varied or constant) for five typically developing infants to increase head elevation and decrease negative vocalizations during tummy time. Improvements occurred in infant performance regardless of the preferred items used. In addition, the mothers who implemented the tummy time procedures found the treatment to be socially valid and were more likely to select the use of the constant item when given the opportunity to choose.

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.

A Clinical Trial Based on Reward Contingency to Improve Prone Tolerance and Motor Development is Feasible in 3- to 6-Month-Old Infants

Aims: The American Academy of Pediatrics recommends “parents to incorporate supervised, awake ‘prone play’ in their infant’s routine to support motor development and minimize the risk of plagiocephaly”. The purpose of this feasibility study was to compare usual care to a reward contingency–based intervention, developed to increase prone tolerance and improve motor skills. Methods: Ten full-term infants, 3–6- months old, with poor prone tolerance were randomized to either the Education group or Reward contingency group. Each group participated in three parent education sessions and 15 intervention sessions, over the period of three weeks. Infants in the Reward contingency group used the Prone Play Activity Center, a technology developed to reinforce motor behavior of infants in prone position. Intervention frequency and parent feedback data determined the feasibility of the interventions. Results: Infants in the Reward contingency group practiced a median of 12 of the 15 anticipated intervention sessions in the Prone Play Activity Center. These infants used the device for a mean of 18 minutes per day. Parents of infants in the Education group practiced a median of 10 sessions of the 15 anticipated intervention sessions. Conclusion: The reward contingency–based intervention is feasible for use in a future clinical trial with some modifications.

Feasibility and Safety of the Preemie Orthotic Device to Manage Deformational Plagiocephaly in Extremely Low Birth Weight Infants

BACKGROUND

Premature infants are predisposed to developing deformational plagiocephaly. Deformational plagiocephaly may affect the infant's social well-being and neurobehavioral development.

PURPOSE

This pilot study investigated the feasibility and safety of the preemie orthotic device (POD); a noncommercial, supportive orthotic device to manage deformational plagiocephaly.

METHODS

The setting for this prospective, descriptive, phase 1 clinical trial was 2 urban and 1 suburban neonatal intensive care units that provided care for critically ill premature and term infants. Participants included a convenience sample of 10 premature extremely low-birth-weight infants weighing less than 1 kg. All participants received the experimental treatment with the POD. Time spent on the device with and without the supportive foam insert, provider perception, adverse events, and head shape measurements were collected to assess feasibility and safety of the device.

RESULTS

Participants had a median gestational age of 25.4 weeks and median birth weight of 0.673 kg. The POD was used a median of 21.2 hours per day and the foam insert was used a median of 11.1 hours per day. At enrollment, 1 participant had a normal cranial index compared with 5 participants at study completion. All participants had normal cranial symmetry at study enrollment and completion. No device-related adverse events were reported.

IMPLICATION FOR PRACTICE

The POD was found to be feasible and safe. Staff had favorable responses to the device. Recommendations by nursing staff included enlarging the device to extend its use.

IMPLICATION FOR RESEARCH

Further studies are warranted to assess the POD's effectiveness.

Parents' Perspectives and Clinical Effectiveness of Cranial-Molding Orthoses in Infants With Plagiocephaly

OBJECTIVE

To investigate the clinical effectiveness of and parents' perspectives on cranial-molding orthotic treatment.

METHODS

Medical charts were reviewed for 82 infants treated for plagiocephaly with cranial-molding orthoses in our clinic from April 2012 to July 2016 retrospectively. Infants who were clinically diagnosed with positional plagiocephaly and had a Cranial Vault Asymmetry Index (CVAI) of more than 3.5% were included. Pre- and post-treatment CVAI was obtained by three-dimensional head-surface laser scan. Parents' perceptions of good outcome (satisfaction) were evaluated with the Goal Attainment Scale (GAS). The GAS score assessed how much the parent felt that his or her initial goal for correcting the skull asymmetry was achieved after the treatment.

RESULTS

The compliance with cranial-molding orthoses was 90.2% (74 of 82 infants). There were 53 infants (65% of the 82 infants) who had adverse events with the cranial-molding orthoses during the study. Heat rash was found in 29 cases (35.4%) and was the most common adverse event. The mean GAS T-score was 51.9±10.2. A GAS T-score of 0 or more was identified for 71.6% of parents. The GAS T-score was significantly related to the age (p<0.001), the initial CVAI, and the difference of CVAI during the treatment (p<0.001).

CONCLUSION

Parents' perception of good outcome was correlated with the anthropometric improvement in cranialmolding orthotic treatment in infants with plagiocephaly. A high percentage of parents felt that the treatment met their initial goals in spite of a high occurrence of adverse events.

Assessing calvarial vault constriction associated with helmet therapy in deformational plagiocephaly

OBJECTIVE Deformational plagiocephaly and/or brachycephaly (DPB) is a cranial flattening frequently treated in pediatric craniofacial centers. The standard of care for DPB involves patient positioning or helmet therapy. Orthotic therapy successfully reduces cranial asymmetry, but there is concern over whether the orthotics have the potential to restrict cranial growth. Previous research addressing helmet safety was limited by lack of volume measurements and serial data. The purpose of this study was to directly compare head growth data in patients with DPB between those who underwent helmet therapy and those who received repositioning therapy. METHODS This retrospective cohort study analyzed pre- and posttherapy 3D photographs of 57 patients with DPB who had helmet therapy and a control group of 57 patients with DPB who underwent repositioning therapy. The authors determined the change in cranial vault volume and cranial circumference between each patient's photographs using 3D photogrammetry. They also computed a cubic volume calculated by multiplying anterior-posterior diameter, biparietal diameter, and height. Linear regressions were used to quantify effects of age and therapy type on these quantities. RESULTS A comparison of the following variables between the two groups yielded nonsignificant results: age at the beginning (p = 0.861) and end (p = 0.539) of therapy, therapy duration (p = 0.161), and the ratio of males to females (p = 0.689). There was no significant difference between patients who underwent helmeting versus positioning therapy with respect to change in either volume calculation or head circumference z-score (p ≥ 0.545). Pretherapy photograph age was a significant predictor of cranial growth (p ≤ 0.001), but therapy type was not predictive of the change in the study measurements (p ≤ 0.210). CONCLUSIONS The authors found no evidence that helmet therapy was associated with cranial constriction in the study population of patients with DPB. These results strengthen previous research supporting helmet safety and should allow health care providers and families to choose the appropriate therapy without concern for potential negative effects on cranial growth.

Paleopathological Findings of Dry Skulls with Plagiocephaly

In literature, plagiocephaly is defined as abnormal asymmetrical head shape with unilateral flattening of the anterior and/or posterior part of the skull. It is classified as synostotic or deformational. Synostotic plagiocephaly is the result of premature unilateral fusion of neurocranim sutures. Positional plagiocephaly is caused by asymmetrical intrauterine and/or postnatal external forces. The authors report findings of both types of plagiocephaly in the dry skull collection from pertaining Broumov Ossuary (13th–18th century), Czech Republic. In the paper, the incidence of paleopathological asymmetrical skull deformities is discussed in the context with recent clinical data.

Six month-old infants with deformational plagiocephaly do not differ from unaffected infants with respect to vocal control

OBJECTIVES

The recommendation of a supine sleeping position led to a significant reduction of SIDS, but increased positional skull deformities (DP). Here, a quantitative analysis of babbling aims to complement previous studies of language-relevant competence based on items of the Bayley-scales that suggested the presence of developmental language delays in DP infants. Measures of fundamental frequency variability as proxies for vocal control are well suited for testing this assumption, since the laryngeal neuro-muscular system matures early and is coupled with brain function while working rapidly in coordinating the structures and mechanisms involved in infant sound production.

METHODS

Sixty-six healthy, full-term infants with normal hearing and a monolingual background took part: (1) moderately asymmetrical DP group - N = 41; 21 male; (2) severely asymmetrical DP group - N = 10; 8 male; and (3) controls - N = 15; 5 male (group assignment based on stereophotogrammetric 360° scans). Fundamental frequency (fo) measures were taken as proxies for vocal control skills during babbling.

RESULTS

A MANOVA revealed no significant multivariate effect for the shape group, Wilks' λ = 0.86, F(2, 63) = 1.21, p = 0.30, η2 = 0.07 (medium effect-size). The results do not support previous findings based on Bayley scale evaluations that suggested a negative impact of DP on language development during infancy.

CONCLUSIONS

A strong link between DP and brain dysfunction affecting vocal control, which would cause deviations in otherwise healthy DP infants, was not observed. Objective long-term studies of sound production are necessary to identify and/or understand the potential consequences of DP on early language development.

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

AIMS

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSION

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

Infant Positioning, Baby Gear Use, and Cranial Asymmetry

Objectives This study aimed to identify predictors of cranial asymmetry. We hypothesize that among infants diagnosed with cranial asymmetry in the sampled region, there is an association between exposure to more time in baby gear and less awake time in prone and side-lying than in infants who do not present with this condition. Methods The study employed a cross sectional survey of caregivers of typically developing infants and infants diagnosed with cranial asymmetry. Results A mutivariable model reveals that caregivers of children who are diagnosed with cranial asymmetry report their children spending significantly less time in prone play than those children without a diagnosis of cranial asymmetry. Side-lying and time spent in baby gear did not attain statistical significance. Conclusions for Practice Occupational therapists, physical therapists, pediatricians, nurses and other health care professionals must provide parents with early education about the importance of varying positions and prone play in infancy and address fears and concerns that may serve as barriers to providing prone playtime.

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.

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

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

MAIN FINDINGS

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

CONCLUSION

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

Positional plagiocephaly following ventriculoperitoneal shunting in neonates and infancy-how serious is it?

PURPOSE

We test the hypothesis that ventriculoperitoneal (VP) shunt insertion significantly increases contralateral positional plagiocephaly.

METHODS

We reviewed 339 children who had a VP shunt inserted at Birmingham Children's Hospital between 2006 and 2013, noting laterality of shunt insertion and frontal or occipital position. We ascertained the presence of post-operative positional plagiocephaly using the cranial vault asymmetry index. Multinomial logistic regression modelling was used to examine relationships between plagiocephaly, shunt position, gender and age. Adjusted odds and risk ratios for effect of variables on plagiocephaly were calculated.

RESULTS

Children with occipital VP shunts are at significant risk of developing contralateral positional plagiocephaly, particularly in the first 12 months of life.

CONCLUSIONS

We recommend careful follow-up and advice regarding head positioning following surgery. There should be consideration for active monitoring to avoid plagiocephaly, including physiotherapy and health visitor interventions. Endoscopic third ventriculostomy in selected cases or anterior shunt placement could be considered. A larger national study would be of interest to evaluate the extent of an otherwise correctable problem.

Plagiocephaly and Developmental Delay: A Systematic Review

OBJECTIVE

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

STUDY DESIGN

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

RESULTS

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

CONCLUSION

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

Orthotic Management of Deformational Plagiocephaly: Consensus Clinical Standards of Care

Objective

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

Design

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

Setting

Electronic survey delivery.

Participants

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

Results

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

Conclusions

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

Repercussions of plagiocephaly on posture, muscle flexibility and balance in children aged 3-5 years old

AIM

The objective of the study was to assess posture, muscle flexibility and balance in children aged 3-5 years old with a history of nonsynostotic plagiocephaly.

METHODS

Fifty-two children with previous history of plagiocephaly were evaluated, along with 52 control subjects matched for age, sex, height, weight and physical activity. The outcome measures included static posture, assessed through the measurement of angles and distances between anatomical landmarks; muscle flexibility, evaluated with the Stibor, Shober and finger-to-floor distance tests and balance, assessed by the Pediatric Balance Scale.

RESULTS

One-way analysis of variance afforded statistically significant differences (P < 0.05) in head position, muscle flexibility (thoracic mobility and trunk and lower limbs muscle shortening) and balance.

CONCLUSION

Children with previous history of non-synostotic plagiocephaly present changes in head position, muscle shortening and a poor balance when compared to control children at 3-5 years old.

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.

Custom made orthotic device for maintaining skull architecture during the postoperative period in infants undergoing craniosynostosis surgery

AIM

To fabricate a cost effective, indigenous and simple orthotics helmet for post-operative cranial molding in patients with craniosynostosis surgery.

METHODS

We present a case of 15 month old infant with secondary cranial vault deformity. Cranial vault remodeling surgery involving the posterior skull was planned and executed to increase the posterior gap, so that brain growth would be facilitated towards this empty space. Materials such as thermoplastic sponge, thermoplastic ionomer resin sheet, soft sponge and Velcro straps are used to fabricate a cranial orthotics helmet.

RESULTS

We have successfully used the above materials to fabricate the orthotics helmet for post-operative cranial molding.

CONCLUSION

The technique described in this article is simple and cost effective. It can be custom made according to the demands of the surgical technique and the type of synostosis. It favors an individualistic prognosis, and proves worthwhile as every synostosis requires a unique treatment plan. It is an excellent adjuvant to craniosynostosis remodeling surgery.

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

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

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

BACKGROUND

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

OBJECTIVE

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

DESIGN

This was a prospective cohort study.

METHODS

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

RESULTS

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

LIMITATIONS

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

CONCLUSIONS

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

Cranial shape, size and cervical motion in normal newborns

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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