Prevention of Deformational Plagiocephaly in Hospitalized Infants Using a New Orthotic Device

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

A pilot exploratory study examining the potential influence of continuous positive airway pressure devices on cranial molding trajectories in preterm infants

OBJECTIVE

The objective of this exploratory study was to assess the potential impacts of two different continuous positive airway pressure (CPAP) devices on preterm infant head shape and circumference.

STUDY DESIGN

Twenty infants born at <32 weeks gestational age requiring CPAP support were enrolled. Ten infants used the Hudson RCI Nasal Prong CPAP device and 10 infants used the Fisher-Paykel CPAP device. Infant Cranial Index (CI) and head circumference (HC) were collected weekly as well as infant gestational age at birth, and total number of days on CPAP.

RESULTS

At baseline, average total birthweight of infants was 1021 grams (SD = 227 grams), average gestational age was 26.9 weeks (SD = 1.80), mean CI was 79.7 cm (SD = 5.95), and HC was 10.2 cm (SD = 0.92). Days on CPAP ranged from 16 to 63 days, with an average of 40.7 (SD = 13.6) days. Neither CI nor HC differed by device type; however, the Fisher-Paykel device was associated with slightly greater HC growth rate.

CONCLUSION

CPAP devices and the pressures they apply plausibly contribute to preterm infant cranial molding over time, with the greatest potential impact on infants who require CPAP support for longer periods; however, these findings must be validated in larger cohorts. Additionally, positioning practices should be further examined to determine how they may contribute to or prevent the development of cranial molding deformity.

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

Background

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

Aim

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

Study design

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

Results

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

Conclusion

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

[Difficulties in differential diagnosis of sagittal synostosis (scaphocephaly)]

Craniosynostosis is characterized by congenital absence or premature closure of skull sutures. The most common form of craniosynostosis is synostosis of sagittal suture followed by scaphocephaly. There are some head deformities similar to scaphocephaly such as positional and constitutional dolichocephaly, etc. These patients have no sagittal suture synostosis. However, there are difficulties in differential diagnosis between these deformities and scaphocephaly.

OBJECTIVE

To develop differential diagnostic criteria between dolichocephalic head deformities and true scaphocephaly following sagittal synostosis.

MATERIAL AND METHODS

The study included 33 patients with dolichocephaly (25 (75.8%) boys and 8 (24.2%) girls) between December 2013 and August 2022. The inclusion criterion was available CT or ultrasound data confirming or excluding sagittal synostosis. Age of patients was 8.62±7.71 (1.77-36) months. We analyzed anamnestic, clinical and radiological data. Radiological data was compared with diagnostic findings in 20 patients with scaphocephaly. Both groups were comparable in age, gender and cranial index.

RESULTS

We present clinical and radiological signs, as well as algorithm for differential diagnosis between scaphocephaly and dolichocephaly.

CONCLUSION

There are objective difficulties in differential diagnosis between scaphocephaly following sagittal synostosis and dolichocephalic head deformities. In most cases, we cannot establish the cause of congenital forms of dolichocephaly. The most likely causes may be pre- and postnatal compressive and positional effects. Ultrasound of skull sutures is preferable for differential diagnosis between these abnormalities. Correction of dolichocephaly can be carried out according to aesthetic indications with individual cranial orthoses.

Delayed Presentation of Unicoronal Craniosynostosis-Masked by Ipsilateral Posterior Deformational Plagiocephaly

Despite a greater awareness of the differential diagnosis of head shape abnormalities among pediatricians, the effect of deformational forces on calvarial morphology can complicate the diagnosis of craniosynostosis. In this report, we describe 2 patients diagnosed with unicoronal craniosynostosis (UCS) in a delayed fashion due to the presence of concomitant posterior deformational plagiocephaly (PDP). In both cases, the severity of each patients' PDP obscured changes typically associated with UCS. This unique presentation underscores the importance of having a high index of suspicion for possible premature suture fusion despite the presence of concomitant PDP.

A Vision for Excellence by Design

Generating evidence for care improvement has characterized my program of research spanning 20 years. Six domains are highlighted to advance the science and practice of critical care nursing in today's complex health care systems. Employee well-being and taking care of team members are key priorities for successful leaders. Understanding that patient and staff outcomes are inextricably linked strengthens the need for care environments to be healing and holistic for staff and patients. The American Association of Critical-Care Nurses' Healthy Work Environment framework empowers staff and optimizes the experience for patients, their families, and care teams. Appropriate staffing, guided by contemporary acuity measurement, takes into account the cognitive workload and complexity of nursing. Committing to a culture of certification and ensuring staffing models with appropriately educated and experienced nursing staff will remain important. In the past decade, we have established the impact of these specific nursing characteristics on improved patient outcomes. Understanding the attributes of empathic and empowered teams is requisite for authentic leadership. Interventions to mitigate moral distress are necessary to foster moral resilience among critical care nurses. The challenge for the future will be to support organizational health through the coexistence of highly reliable processes and clinical innovation. Excellence is achieved when systems are designed to support professional practice and clinical teams and environments.

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.

Use of a Midliner Positioning System for Prevention of Dolichocephaly in Preterm Infants

PURPOSE

The purpose of this study was to determine effectiveness of a midliner positioning system (MPS, Tortle Midliner) for preventing dolichocephaly.

METHODS

This was a nonrandomized, prospective study of 30 premature infants (study cohort, SC) using an MPS compared with a retrospective study cohort (RSC) of 65 infants who received standard of care intervention.

RESULTS

RSC baseline cranial index (CI) of 80% and final CI of 77% significantly decreased over an average 5.5 weeks (P < .0001). The SC baseline CI and the final CI were both 79% over an average 5.7 weeks, indicating no significant difference between CI measures (P = .6). Gestational age, birth weight, reflux, time on continuous positive airway pressure, and time in a supine position were not associated with dolichocephaly.

CONCLUSIONS

The SC developed less cranial molding (ie, had greater CI), compared with the RSC. A larger randomized study is needed to recommend routine use of MPS for prevention and/or treatment of cranial molding in premature infants.

Excellence by Design: The Patricia A. Hickey Award for Excellence in Cardiovascular Nursing

This award reflects the high-impact contributions of pediatric critical care nurses that have helped to shape the field. Lessons from an ongoing career in nursing leadership are shared by Dr Patricia Hickey. Four themes are highlighted which include (1) our role models/mentors, (2) our profession and its impact, (3) our teams and environments of excellence, and (4) our bright future. Program and practice excellence does not just happen. It requires strategic thinking, deliberative processes, risk-taking and guts to create and sustain. A bright future is forecasted with stellar contributions of professional nurses and interprofessional cardiac critical care teams.