Prevalence, risk factors, and natural history of positional plagiocephaly: a systematic review

Cranial remolding orthosis for children with deformational skull deformities: A systematic review on the factors affecting success and duration of treatment

Deformational plagiocephaly, deformational brachycephaly, and deformational scaphocephaly are the most common types of skull deformities during the first year of life. Using a cranial remolding orthosis (CRO) can have an important role in achieving a satisfactory level of improvement in symmetry and proportion of the deformed skulls. However, there is no consensus on the most important parameters for the success or length of treatment with a CRO. In this study, we did a systematic literature review in PubMed, Scopus, Web of Science, and EMBASE on January 2023. Titles/abstracts of the found studies were screened by two independent reviewers. The Newcastle-Ottawa Scale was used to evaluate the quality of the included articles. The best evidence synthesis was considered to determine the strength of the reported factors. A total of 25 articles with an accumulated sample of 7594 participants were included. Nine predictive factors, including age at initiation of CRO treatment, CRO compliance, deformity severity, deformity type, torticollis, gestational age, gestational type, delivery method, and developmental delay, were considered for CRO treatment length or success. Moderate evidence suggests that CRO treatment length is linked to a patient's age at the start of treatment and the deformity severity. Moreover, treatment success is correlated with a patient's age at the start of treatment, CRO compliance, and deformity severity. Moderate evidence indicates that there is no relationship between the presence of torticollis and gestational age with CRO treatment success.

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.

Smartphone Photogrammetric Assessment for Head Measurements

The assessment of cranial deformation is relevant in the field of medicine dealing with infants, especially in paediatric neurosurgery and paediatrics. To address this demand, the smartphone-based solution PhotoMeDAS has been developed, harnessing mobile devices to create three-dimensional (3D) models of infants' heads and, from them, automatic cranial deformation reports. Therefore, it is crucial to examine the accuracy achievable with different mobile devices under similar conditions so prospective users can consider this aspect when using the smartphone-based solution. This study compares the linear accuracy obtained from three smartphone models (Samsung Galaxy S22 Ultra, S22, and S22+). Twelve measurements are taken with each mobile device using a coded cap on a head mannequin. For processing, three different bundle adjustment implementations are tested with and without self-calibration. After photogrammetric processing, the 3D coordinates are obtained. A comparison is made among spatially distributed distances across the head with PhotoMeDAS vs. ground truth established with a Creaform ACADEMIA 50 while-light 3D scanner. With a homogeneous scale factor for all the smartphones, the results showed that the average accuracy for the S22 smartphone is -1.15 ± 0.53 mm, for the S22+, 0.95 ± 0.40 mm, and for the S22 Ultra, -1.8 ± 0.45 mm. Worth noticing is that a substantial improvement is achieved regardless of whether the scale factor is introduced per device.

Neurocognitive Outcomes in Deformational Plagiocephaly: Is There an Association between Morphologic Severity and Results?

BACKGROUND

The neurodevelopmental effects of skull asymmetry and orthotic helmet therapy for deformational plagiocephaly (DP) have had limited investigation. This study assessed the long-term neurocognitive outcomes in patients with DP and their association with orthotic helmet therapy and head shape abnormality.

METHODS

A total of 138 school-age children with a history of DP, 108 of whom received helmet therapy, were tested with a neurocognitive battery assessing academic achievement, intelligence quotient, and visual-motor function. Severity of presenting plagiocephaly was calculated using anthropometric and photometric measurements. Analysis of covariance was used to compare outcomes between helmeted and nonhelmeted cohorts, unilateral plagiocephaly and concomitant brachycephaly, and left-sided and right-sided plagiocephaly. The association between severity of plagiocephaly and neurocognitive outcome was assessed through a residualized change approach.

RESULTS

There were no significant differences in neurocognitive outcomes between the helmeted and nonhelmeted DP cohorts or the unilateral plagiocephaly and brachycephaly cohorts. Participants with left-sided DP had significantly lower motor coordination scores than participants with right-sided DP (84.8 versus 92.7; effect size = -0.50; P = 0.03). There was a significant laterality by cephalic index interaction, with a negative association between cephalic index and reading comprehension and spelling for participants with left-sided DP. No significant associations were found between severity of presenting or posttreatment deformity and neurocognitive outcome.

CONCLUSIONS

Pretreatment and posttreatment severity of plagiocephaly were not correlated with neurocognitive function at school age. Helmet therapy was not associated with better or worse long-term neurocognitive function. However, participants with left-sided DP demonstrated worse neurocognitive outcomes than participants with right-sided DP in the domains of motor coordination and some types of academic achievement.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Effectiveness of Conservative Treatments in Positional Plagiocephaly in Infants: A Systematic Review

OBJECTIVE

The objective of this study is to analyze conservative treatments implemented to manage positional plagiocephaly in infants.

METHODS

This is a systematic review conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, performed in the Medline (PubMed), Scopus, Web of Science, and Cochrane databases. Articles were selected according to the eligibility criteria, regarding the effectiveness of conservative treatments in positional plagiocephaly in infants, published in the last 10 years with a score ≥3 in the PEDro Scale.

RESULTS

A total of 318 articles were identified and 9 of them were finally selected.

CONCLUSIONS

Physical therapy treatment is considered as the first line of intervention in plagiocephaly with non-synostotic asymmetries and manual therapy is the method that obtains the best results within this intervention. In cases of moderate or severe plagiocephaly, helmet therapy can be an effective second-line intervention; however, the best way to prevent this condition is through counseling of parents or caregivers, and early treatment is essential for optimal therapeutic outcomes. The review was registered in PROSPERO (CDR42022306466).

Research into the correlation between positional skull deformation and motor performance of infants aged under 4 months

OBJECTIVE

To investigate the correlation between positional skull deformation (PD) and motor performance of infants under 4 months of age.

METHODS

Infants aged under 4 months were enrolled in the children's healthcare and the premature infants follow-up Clinic of the Second Affiliated Hospital of Army Military Medical University. The cranial vault asymmetry (CVA) and cephalic index (CI) were calculated in all infants, and the infant motor performance test (TIMP) was used to evaluate the infant motor performance. The motor performances of infants with different types and degrees of PD were compared, so were the incidences of PD in infants with different motor performance levels.

RESULTS

Overall, 2118 infants were recruited and divided according to the types of PD and TIMP scores. The comparison of TIMP scores within different types of PD at different months of age showed that, regardless of the types of PD, TIMP scores of infants with PD were lower than those of normal infants. In particular, the difference in TIMP scores was statistically significant (P < 0.05) in infants with dolichocephaly, plagiocephaly,dolicho-plagiocephaly and brachy-plagiocephy. In addition, the comparison of CVA values of infants with different TIMP score levels at different months of age showed that the CVA values of the extremely low-level group were significantly higher than those of the medium-level and high-level group, especially in the 3-month-old and 4-month-old groups, which showed significant statistical differences (P < 0.05).

CONCLUSIONS

PD and motor performance of infants aged under 4 months seem to interact and influenc each other. The more serious the severity of PD were,the worse the motor performance of infants. Conversely, the incidence of PD increased in infants with poor motor performance.

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

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

Disparities in Access to Cranial Remodeling Orthosis for Deformational Plagiocephaly

OBJECTIVE

Moderate to severe cases of deformational plagiocephaly (DP) may be treated with cranial remolding orthoses (CRO). This study investigated the socioeconomic disparities in access to care for CRO for DP correction.

DESIGN

This was a retrospective review of medical records from a single CRO company in Connecticut from 2014 to 2020.

METHODS

Demographic variables were collected from all patients. Univariable logistic regressions were used to identify differences for presenting age at consultation, whether CRO was pursued, and length of CRO treatment by insurance payor and household income quartile.

RESULTS

Of the 5620 patients identified, 4100 (73.0%) received CRO, with 674 (12.0%) receiving a second helmet. Of those receiving CRO, 1536 (37.5%) had Medicaid insurance while 2558 (62.4%) were commercially insured. Patients on Medicaid were 1.30 times more likely to have delayed presentation (P  =  .017), while patients from the lowest income quartile were 1.26 1.50 (P < .001) and 1.58 (P < .001) times more likely to have a delayed presentation relative to those in the highest and second-highest income quartiles, respectively. Patients in the highest and second-highest income quartiles were also 1.55 (P < .001) and 1.45 (P < .001) more likely, respectively, to receive CRO after consultation than those from the lowest income quartile.

CONCLUSIONS

Lower income and Medicaid-insured patients had delayed presentation for CRO consultation. Those from the lowest income quartile were more likely to never receive CRO than those from wealthier backgrounds. Low socioeconomic status and Medicaid insurance, which can have more restrictive coverage policies for CRO, may result in the delayed treatment of DP.

Positional Plagiocephaly and Craniosynostosis

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

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..

Facial asymmetry in children with either unilateral lambdoid craniosynostosis or positional posterior plagiocephaly

BACKGROUND

In unilateral lambdoid craniosynostosis (ULC), the posteriorly situated lambdoid suture of the cranial vault fuses prematurely. Positional posterior plagiocephaly (PPP) causes flattening of the posterior side of the head, either through external forces or through underlying differences in brain development. Both conditions cause occipital flattening of the head, but the aetiology is different.

MATERIALS AND METHODS

Eight ULC children were compared with 16 sex- and age-matched PPP children. 3D computer tomography scans of all 24 children were analysed with Dolphin imaging software. The location and symmetry of the temporomandibular joint (Co), and the symmetry of the maxillary anterior nasal spine (ANS) and the mandibular symphysis (Pgn) were analysed. Furthermore, the mandibular bone (Co-Pgn) length, corpus length, ramus height, positional changes in the external acoustic meatus (PoL) and the distance from the orbital margin to the articular fossa were measured.

RESULTS

In all eight ULC children, the Co was anteriorly displaced on the affected side compared with the unaffected side. In all ULC and PPP children, the ANS, which is considered the bony maxillary midpoint, was shifted towards the affected side. In all ULC children, the mandibular bone (Co-Pgn) was shorter on the affected side. The PoL was antero-inferiorly positioned in all ULC children on the affected side compared with the unaffected side.

CONCLUSIONS

Our results show that both types of posterior plagiocephaly are associated with an asymmetric position of the Co and asymmetry of the mandible and maxilla. Facial asymmetry was more frequently seen in ULC than PPP children.

The Obstetrician Gynecologist's role in the screening of infants at risk of severe plagiocephaly: Prevalence and risk factors

This study was conducted to determine the prevalence, maternal and/or neonatal risk factors for severe plagiocephaly in order to early detect and refer infants at risk. A prospective observational study was conducted, involving 4337 infants who visited the Perinatology Center at San Pietro Fatebenefratelli Hospital in Rome, evaluated following the Plagiocephaly Severity Scale of Atlanta. ©The plagiocephaly prevalence resulted 1.89%, considering moderate to severe forms. Maternal risk factors include primiparity, older age, gestational diabetes, and uterine fibromatosis. Neonatal risk factors are early term gestational age, low weight, twin pregnancy, and prolonged labor with an emergency cesarean section. Screening for severe plagiocephaly should begin antenatally. Although the low prevalence, identifying infants at risk can prevent potential permanent sequelae. We suggest a multidisciplinary approach for the management of plagiocephaly, involving the figure of the Obstetrician Gynecologist, who can highlight the risk factors ranging from obstetric and birth conditions.

Somatosensory evoked potentials are abnormal with plagiocephaly

Background

Deformational plagiocephaly is usually managed conservatively, as it tends to improve over time and with the use of conservative measures. However, before the year 2017 we operated on patients with severe plagiocephaly and neurological symptoms at the Helsinki Cleft Palate and Craniofacial Center.

Methods

Of the 20 infants with severe deformational plagiocephaly and neurological symptoms referred to us between 2014 and 2016, 10 underwent cranioplasty open reshaping of the posterior cranial vault. The parents of the last 10 patients were given information on the natural history of the condition and the patients were followed up with an outpatient protocol. The aim of this study was to gain information on the brain electrophysiology and recovery of patients after total cranial vault reconstruction by measuring the electroencephalogram (EEG) somatosensory evoked potentials (SEP; median nerve).

Results

Of the 10 participants in the operation arm, six had abnormal SEP at least on the affected cerebral hemisphere and all SEPs were recorded as normal when controlled postoperatively. In the follow-up arm, eight out of 10 participants had abnormal SEP at the age of approximately 24 months, and all had normalized SEPs at control visits.

Conclusion

Our data suggest that cranioplasty open reshaping of the posterior cranial vault did not affect abnormal SEP-EEG recordings. We have abandoned the operations in deformational plagiocephaly patients due to findings suggesting that expanding cranioplasty is not beneficial for brain function in this patient group.

Cranial Shape in Infants Aged One Month Can Predict the Severity of Deformational Plagiocephaly at the Age of Six Months

In this study, we aimed to monitor changes in cranial shape using three-dimensional (3D) scanning to determine whether the severity of deformational plagiocephaly (DP) at the age of 6 months could be predicted at the age of 1 month. The cranial shape was measured at the ages of 1, 3, and 6 months (T1, T2, and T3, respectively) in 92 infants. We excluded those who received helmet treatment before T3. The cranial vault asymmetry index (CVAI) using 3D scanning was evaluated in all infants. DP was defined as a CVAI > 5.0% with mild (CVAI ≤ 6.25%) or moderate/severe severity (CVAI > 6.25%). The CVAI cut-off value at T1 for severe DP at T3 was determined using receiver operating characteristic (ROC) curves. At T1, T2, and T3, the respective CVAI median values were 5.0%, 5.8%, and 4.7% and the DP incidence was 50.0%, 56.8%, and 43.2%, respectively. The DP severity temporarily worsened from T1 to T2 but then improved at T3. Among the infants, 73.9% had a similar DP severity at T1 and T3 (p = 1.0). A ROC curve analysis revealed a CVAI cut-off value of 7.8% at T1 predicted severe DP. It was concluded that later DP severity could be predicted using 3D scanning at T1 with properly defined cut-off values.

Spherical harmonics to quantify cranial asymmetry in deformational plagiocephaly

Cranial deformation and deformational plagiocephaly (DP) in particular affect an important percentage of infants. The assessment and diagnosis of the deformation are commonly carried by manual measurements that provide low interuser accuracy. Another approach is the use of three-dimensional (3D) models. Nevertheless, in most cases, deformation measurements are carried out manually on the 3D model. It is necessary to develop methodologies for the detection of DP that are automatic, accurate and take profit on the high quantity of information of the 3D models. Spherical harmonics are proposed as a new methodology to identify DP from head 3D models. The ideal fitted ellipsoid for each head is computed and the orthogonal distances between head and ellipsoid are obtained. Finally, the distances are modelled using spherical harmonics. Spherical harmonic coefficients of degree 2 and order − 2 are identified as the correct ones to represent the asymmetry characteristic of DP. The obtained coefficient is compared to other anthropometric deformation indexes, such as Asymmetry Index, Oblique Cranial Length Ratio, Posterior Asymmetry Index and Anterior Asymmetry Index. The coefficient of degree 2 and order − 2 with a maximum degree of 4 is found to provide better results than the commonly computed anthropometric indexes in the detection of DP.

Reference Values for Cranial Morphology Based on Three-dimensional Scan Analysis in 1-month-old Healthy Infants in Japan

Currently, molded helmet therapy is used to treat infants with deformational plagiocephaly. However, the indices of normal cranial shape remain unclear, and thus, the prevalence of deformational plagiocephaly is unknown, particularly in Japan. We investigated the reference values for cranial morphological characteristics in 1-month-old Japanese infants using a three-dimensional scanner, to determine the prevalence of deformational plagiocephaly. One hundred fifty-three healthy infants who visited three hospitals (from April 2020 to March 2021) were enrolled. Cranial shape was measured using a three-dimensional scanner and was analyzed using image analysis software. Outcome measures were cranial volume, length, width, length-width ratio, circumference, asymmetry, and vault asymmetry index; cephalic index; and anterior, posterior, and overall symmetry ratios. The cranial vault asymmetry index >3.5% or ≥10% were diagnosed as deformational or severe deformational plagiocephaly, respectively. The mean age at measurement was 35.7 days. The mean cranial volume was 559 mL; cranial length, 129 mm; cranial width, 110 mm; length-width ratio, 118%; cephalic index, 85.2%; cranial circumference, 377 mm, cranial asymmetry, 6.4 mm; cranial vault asymmetry index, 5.0%; and anterior, posterior, and overall asymmetry ratios, 93.1%, 91.3%, and 96.4%, respectively. The prevalence of deformational and severe deformational plagiocephaly was 64.7% and 6.6%, respectively. Sex-based differences were observed for cranial volume and width. The results obtained in this study can be considered standard values that can facilitate the differentiation of abnormal infant cranial morphological characteristics for Japanese medical practitioners.

Most common infant health concerns in osteopathic practices in Germany. A survey

BACKGROUND

In Germany, more parents have been seeking help from osteopaths for their infants and children in recent years. This implies an increasing demand of reliable evidence regarding the effectiveness of osteopathic intervention for this group.

OBJECTIVE

To identify the 'typical' (most common) health concerns of parents when presenting their infants (age 0-12 months) in pediatric osteopathic practices.

METHODS

For the purpose of this survey, well-trained osteopaths who specialize in the treatment of children and infants were selected. A documentation form containing a list of the likely most common infant health problems, developed by means of systematic literature analyses, was provided to experienced osteopaths to assess which health problems were seen most frequently.

RESULTS

Eighty-one osteopaths were contacted, of which 64 (79 %) responded and returned the documentation form. Nine documentation forms could not be evaluated. The remaining 55 documentation forms included information on 2833 health concerns. Quantitatively, there was no dominant health problem, but five problems were found to be common: 21 % of the cases were idiopathic infant asymmetry, 17 % were plagiocephaly, 16 % were excessive crying, and 14 % were feeding and sleep disorders. All other problems were observed as far less frequent. In addition, osteopaths reported 423 other health concerns that were not specified in the documentation form.

CONCLUSIONS

In this survey, infants that were presented in osteopathic practices often had one or more of those five health problems mentioned above. A large observational trial is currently underway to document changes observed during osteopathic treatment of these health problems.

A comparative study between traditional head measurement and structured light three-dimensional scanning when measuring infant head shape

BACKGROUND

This study aimed to evaluate the correlation and consistency between traditional head measurement and structured light three-dimensional (3D) scanning parameters when measuring infant skull shape.

METHODS

A total of 76 infants aged 3 months to 2.5 years old were included in the study. Head circumference (HC) was measured with a tape measure. The transverse, anteroposterior, and oblique diameters were measured using a spreading caliper, and the cranial vault asymmetry index (CVAI) and a cranial index (CI) of symmetry were calculated; 76 cases were measured successfully. The above indexes were measured using a structured light 3D scanning system (71 cases were measured with success). Thus, in the end, the valid data of 71 cases were analyzed, and the measurements of the two approaches were compared.

RESULTS

The 95% confidence interval of traditional head measurement and structured light 3D scanning was between 0.633 and 0.988. Pearson's correlation coefficient indicated a high correlation between the two methods (r=0.793-0.980). The correlation coefficients of the transverse diameter, anteroposterior diameter, and HC, and the CI of symmetry were higher than 0.9. The lowest correlation coefficient for the CVAI was 0.793. The P values of the above measurement data were all <0.001, which indicated that they were closely related. A Bland-Altman plot indicated reasonable consistency between the two methods.

CONCLUSIONS

Both traditional head measurement and structured light 3D scanning are suitable for the measurement of infant head shape. However, while traditional head measurement using a spreading caliper is economical and simple, making it suitable for general screening at a basic level, structured light 3D scanning can deliver additional parameters, which is useful for infants with an abnormal head shape. The latter is also convenient for designing a customized helmet for skull correction when needed.

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.

Efficacy of pediatric integrative manual therapy in positional plagiocephaly: a randomized controlled trial

BACKGROUND

Positional plagiocephaly frequently affects healthy babies. It is hypothesized that manual therapy tailored to pediatrics is more effective in improving plagiocephalic cranial asymmetry than just repositioning and sensory and motor stimulation.

METHODS

Thirty-four neurologically healthy subjects aged less than 28 weeks old with a difference of at least 5 mm between cranial diagonal diameters were randomly distributed into 2 groups. For 10 weeks, the pediatric integrative manual therapy (PIMT) group received manual therapy plus a caregiver education program, while the controls received the same education program exclusively. Cranial shape was evaluated using anthropometry; cranial index (CI) and cranial vault asymmetry index (CVAI) were calculated. Parental perception of change was assessed using a visual analogue scale (- 10 cm to + 10 cm).

RESULTS

CVAI presented a greater decrease in PIMT group: 3.72 ± 1.40% compared with 0.34 ± 1.72% in the control group (p = 0.000). CI did not present significant differences between groups. Manual therapy led to a more positive parental perception of cranial changes (manual therapy: 6.66 ± 2.07 cm; control: 4.25 ± 2.31 cm; p = 0.004).

CONCLUSION

Manual therapy plus a caregiver education program improved CVAI and led to parental satisfaction more effectively than solely a caregiver education program.

TRIAL REGISTRATION

Trial registration number: NCT03659032 ; registration date: September 1, 2018. Retrospectively registered.

Osteopathic Treatment of Infants in Their First Year of Life: A Prospective Multicenter Observational Study (OSTINF Study)

INTRODUCTION

In Germany in recent years, a growing number of parents are seeking help from osteopaths for the perceived health complaints of their infants and children. However, reliable evidence for the effectiveness of osteopathic interventions for this group of patients is largely lacking.

OBJECTIVE

To observe and document changes in the symptoms of certain health disturbances, as perceived by parents, during the course of an osteopathic treatment of their baby, and associated side effects.

METHODS

A single-arm, prospective, multicenter, observational study was chosen as the study design. Parents who contacted an osteopathic practice with any of the following 5 health disturbances were invited to include their baby into the study: idiopathic infant asymmetry (IA), deformational plagiocephaly (DP), feeding disorders (FD), excessive crying (EC), and sleep disorders (SD). Osteopaths performed osteopathic treatment as usual for these conditions, and the parents were asked to rate the perceived severity of symptoms on standardized forms including numerical rating scales (NRS 0-10). In DP, the head circumference of the child's skull was measured with a craniometer, and the cranial vault index (CVAI) was calculated.

RESULTS

230 osteopaths agreed to participate, 151 osteopaths returned parental ratings. 1,136 infants were treated 2.8 ± 1.1 times (mean ± SD). IA was the most prevalent disturbance (48%), followed by EC (18%), FD (15%), DP (14%), and SD (4%). In IA, perceived asymmetry as rated on the NRS improved from 6.1 to 1.1, a mean improvement of 82%. In DP, the CVAI improved from 8.0 to 4.0%, a mean improvement of 51%. FD improved by 77%, EC by 70% (from 7.7 to 2.3 on the NRS) and SD by 56%. Adverse reactions with a timely association with osteopathic treatments were reported in 3.5% of all treatments, probably reflecting typical day-to-day variations in symptoms. In a total of 3,212 treatments, there was not a single serious adverse reaction affecting infant health.

CONCLUSIONS

This is one of the largest studies worldwide to date on the osteopathic treatment of infants. Osteopathic treatment was associated with major positive changes in the severity of perceived health complaints as assessed by parents, which in most cases were resolved as a matter of concern, and was proved to be a safe treatment modality among a large number of therapists. Based on these results, confirmatory intervention studies can and should be planned and conducted.

Comorbidities of deformational plagiocephaly in infancy: a scoping review protocol

INTRODUCTION

Deformational plagiocephaly (DP) is one of the most common cranial shape disorders in infancy. It is characterised by unilateral flattening of the skull due to head preference to one side. The literature suggests that DP is associated with comorbidities such as developmental delay, but the nature and prevalence of the comorbid impairments are still unclear and controversial. Therefore, our scoping review (ScR) aims to explore systematically the extent and nature of literature by identifying, mapping and categorising the most relevant comorbidities of DP in children up to the age of 2 years.

METHODS AND ANALYSIS

This protocol is based on the framework outlined by Arksey and O'Malley. A systematic search will be conducted to identify relevant full text studies from 1992 to 2021 using the databases of Cochrane, MEDLINE, Google Scholar, EMBASE, PubMed and University of Nicosia EBSCO. Two independent reviewers will screen abstracts and full articles in parallel, using specific inclusion and exclusion criteria. Specifically, this review will consider studies investigating DP and relevant comorbidities in children up to the age of 2 years of life without craniosynostosis, torticollis and any other diagnosed neurodevelopmental deficiency.The Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for ScR Checklist will be considered for results' analysis and reporting. The results will be described in a narrative form in relation to the research question and in the context of the overall study purpose.

ETHICS AND DISSEMINATION

Research ethics approval is not required for this ScR since data will be retrieved from publicly available studies. Dissemination activities will include research findings' submission for publication in a relevant peer-reviewed journal and presentation of the results at relevant conferences.

REGISTRATION

Our protocol was registered prospectively with the Open Science Framework (https://osf.io/48am3/).

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.

Applicative Factors of Helmet Molding Therapy in Late-diagnosed Positional Plagiocephaly

BACKGROUND

Although the benefits of helmet therapy for positional plagiocephaly are strongly correlated with age, the effective period remains controversial. However, most physicians agree that effective results can be obtained in patients within the age of 6 months. Owing to the characteristics of positional plagiocephaly in Koreans, many Korean patients have delayed diagnosis, and because this results in delayed onset of the helmet therapy, the outcomes remain largely underevaluated. In the management of late-diagnosed positional plagiocephaly, we aimed to determine the factors affecting the effective application of helmet therapy.

METHODS

We recruited 39 consecutive patients with positional plagiocephaly who received helmet therapy and completed the treatment between December 2008 and June 2016. The ages at initiation and completion of treatment, duration of daily use, initial and final absolute diagonal differences, cephalic index, and cranial vault asymmetry index (CVAI) were analysed using data retrospectively collected from the patients' medical records.

RESULTS

We identified 12 patients with late-diagnosed positional plagiocephaly, of whom 83.33% were effectively treated. The effective change in CVAI (%) was affected by age at treatment initiation (P = 0.001), initial absolute diagonal distance differences (P < 0.001), and initial CVAI (P < 0.001). Up to 9 months, a gradual change of at least 1% CVAI was attained. Treatment initiation at ages < 5.5 months was beneficial. Even at a later age, patients with an initial absolute diagonal distance difference of > 13.50 mm and initial CVAI of > 11.03% could receive effective helmet therapy.

CONCLUSION

The efficacy of helmet therapy in late-diagnosed patients can be predicted on the basis of not only age at treatment initiation, but also initial absolute diagonal distance differences and initial CVAI. We anticipate that even patients with late-diagnosed positional plagiocephaly can expect better helmet therapy outcomes.

Two-Dimensional Image-Based Screening Tool for Infants with Positional Cranial Deformities: A Machine Learning Approach

Positional cranial deformities are relatively common conditions, characterized by asymmetry and changes in skull shape. Although three-dimensional (3D) scanning is the gold standard for diagnosing such deformities, it requires expensive laser scanners and skilled maneuvering. We therefore developed an inexpensive, fast, and convenient screening method to classify cranial deformities in infants, based on single two-dimensional vertex cranial images. In total, 174 measurements from 80 subjects were recorded. Our screening software performs image processing and machine learning-based estimation related to the deformity indices of the cranial ratio (CR) and cranial vault asymmetry index (CVAI) to determine the severity levels of brachycephaly and plagiocephaly. For performance evaluations, the estimated CR and CVAI values were compared to the reference data obtained using a 3D cranial scanner. The CR and CVAI correlation coefficients obtained via support vector regression were 0.85 and 0.89, respectively. When the trained model was evaluated using the unseen test data for the three CR and three CVAI classes, an 86.7% classification accuracy of the proposed method was obtained for both brachycephaly and plagiocephaly. The results showed that our method for screening cranial deformities in infants could aid clinical evaluations and parental monitoring of the progression of deformities at home.

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.

Perceptions and Preferences of Laypersons in the Management of Positional Plagiocephaly

BACKGROUND

Uncertain clinical evidence for treating positional plagiocephaly, especially with helmet therapy, creates difficulties in counseling parents of patients. This study investigates layperson perceptions and treatment preferences for positional plagiocephaly to provide patient-oriented evidence for management.

METHODS

Adult laypersons were recruited through crowdsourcing to view digitally-modified images of normal, mildly, moderately, or severely plagiocephalic infant heads. Participants provided demographic information and rated the infant's head shape and potential related social difficulties, likelihood of consulting a physician for treatment options, and likelihood of seeking helmeting treatment for the infant.

RESULTS

Nine hundred forty-five individuals participated in the study. Perception of head shape, prediction of future embarrassment and social difficulties, likelihood of seeking physician evaluation, likelihood of choosing helmet therapy, and willingness-to-pay for helmet therapy were pairwise-different between 4 plagiocephaly severities (corrected-P < 0.001 for all), except between normocephaly (n = 194) and mild (n = 334) plagiocephaly or between moderate (n = 203) and severe (n = 214) plagiocephaly. Younger respondents were more likely to consult a physician (uncorrected-P = 0.016) and choose helmet therapy (uncorrected-P = 0.004) for infants with normocephaly or mild plagiocephaly. Parents of children with physical disabilities were 6 times as likely as other participants to choose helmet therapy for mild plagiocephaly (corrected-P = 0.036).

CONCLUSIONS

Laypersons perceived moderate and severe plagiocephaly as equally abnormal and mild plagiocephaly as normal, consistent with their treatment preferences. Parents of physically disabled children were significantly more likely than other participants to choose helmet therapy. Our findings provide medical professionals with lay perspectives on positional plagiocephaly that may facilitate effective counseling of parents.

Pediatric cranial deformations: demographic associations

OBJECTIVE

No study has established a relationship between cranial deformations and demographic factors. While the connection between the Back to Sleep campaign and cranial deformation has been outlined, considerations toward cultural or anthropological differences should also be investigated.

METHODS

The authors conducted a retrospective review of 1499 patients (age range 2 months to less than 19 years) who presented for possible trauma in 2018 and had a negative CT scan. The cranial vault asymmetry index (CVAI) and cranial index (CI) were used to evaluate potential cranial deformations. The cohort was evaluated for differences between sex, race, and ethnicity among 1) all patients and 2) patients within the clinical treatment window (2-24 months of age). Patients categorized as "other" and those for whom data were missing were excluded from analysis.

RESULTS

In the CVAI cohort with available data (n = 1499, although data were missing for each variable), 800 (56.7%) of 1411 patients were male, 1024 (79%) of 1304 patients were Caucasian, 253 (19.4%) of 1304 patients were African American, and 127 (10.3%) of 1236 patients were of Hispanic/Latin American descent. The mean CVAI values were significantly different between sex (p < 0.001) and race (p < 0.001). However, only race was associated with differences in positional posterior plagiocephaly (PPP) diagnosis (p < 0.001). There was no significant difference in CVAI measurements for ethnicity (p = 0.968). Of the 520 patients in the treatment window cohort, 307 (59%) were male. Of the 421 patients with data for race, 334 were Caucasian and 80 were African American; 47 of the 483 patients with ethnicity data were of Hispanic/Latin American descent. There were no differences between mean CVAI values for sex (p = 0.404) or ethnicity (p = 0.600). There were significant differences between the mean CVAI values for Caucasian and African American patients (p < 0.001) and rate of PPP diagnosis (p = 0.02). In the CI cohort with available data (n = 1429, although data were missing for each variable), 849 (56.8%) of 1494 patients were male, 1007 (67.4%) of 1283 were Caucasian, 248 (16.6%) of 1283 were African American, and 138 patients with ethnicity data (n = 1320) of Hispanic/Latin American descent. Within the clinical treatment window cohort with available data, 373 (59.2%) of 630 patients were male, 403 were Caucasian (81.9%), 84 were African American (17.1%), and 55 (10.5%) of 528 patients were of Hispanic/Latin American descent. The mean CI values were not significantly different between sexes (p = 0.450) in either cohort. However, there were significant differences between CI measurements for Caucasian and African American patients (p < 0.001) as well as patients of Hispanic/Latin American descent (p < 0.001) in both cohorts.

CONCLUSIONS

The authors found no significant associations between cranial deformations and sex. However, significant differences exist between Caucasian and African American patients as well as patients with Hispanic/Latin American heritage. These findings suggest cultural or anthropological influences on defining skull deformations. Further investigation into the factors contributing to these differences should be undertaken.

Deformational brachycephaly: the clinical utility of the cranial index

OBJECTIVE

The incidence of deformational brachycephaly has risen since the "Back to Sleep" movement in 1992 by the American Academy of Pediatrics. Brachycephaly prevalence and understanding the dynamic nature of the pediatric skull have not been explored in relation to the cranial index (CI). The objective of the study was to determine the prevalence of brachycephaly, via the CI, with respect to time.

METHODS

The authors conducted a retrospective review of 1499 patients ≤ 19 years of age who presented for trauma evaluation with a negative CT scan for trauma (absence of bleed) in 2018. The CI was calculated using CT at the lateral-most point of the parietal bone (cephalic width), and the distance from the glabella to the opisthocranion (cephalic length). Brachycephaly was defined as a CI ≥ 90%.

RESULTS

The mean CI was 82.6, with an average patient age of 6.8 years. The prevalence of deformational brachycephaly steadily decreased from 27% to 4% from birth to > 2 years of life. The mean CI was statistically different between ages < 12 months, 12-24 months, and > 24 months (F[2,1496] = 124.058, p < 0.0005). A simple linear regression was calculated to predict the CI based on age; the CI was found to decrease by 0.038 each month. A significant regression equation was found (F[1,1497] = 296.846, p < 0.0005), with an R2 of 0.140.

CONCLUSIONS

The incidence of deformational brachycephaly is common in infants but decreases as the child progresses through early childhood. Clinicians can expect a significant decrease in mean CI at 12 and 24 months. Additionally, these regression models show that clinicians can expect continued improvement throughout childhood.

Child Abuse and Deformational Plagiocephaly in a West Texas Hospital System

Background  The aim of this study was to assess deformational plagiocephaly’s (DP) predictive value in neglect and physical abuse (nonaccidental trauma [NAT]) within the pediatric population. In addition, we sought to characterize the prevalence of DP and NAT for our hospital’s mostly rural catchment area.

Methods  Data on hospitalized patients diagnosed with NAT and/or neglect between 2012 and 2018 were collected via retrospective chart review. All enrolled children were younger than the age of 4 years at the time of diagnosis, and those without legible head computed tomographies or magnetic resonance images during their initial hospitalization were excluded. Utilizing neuroimaging, we calculated the cranial vault asymmetry index (CVAI) and cranial index for each patient to assess for DP. Differences between the two groups were assessed using Wilcoxon’s rank-sum test for continuous variables and Fisher’s exact test for categorical variables. A p -value of 0.05 or less was considered statistically significant. All analyses were conducted using SAS 9.4 (Cary, North Carolina, United States).

Results  The prevalence of DP within the combined cohort of NAT and neglect patients is 21%, similar to that reported in the literature for the general population (20–50%). There was no significance between the prevalence of DP and a history of NAT ( p > 0.1) or neglect ( p > 0.1). Furthermore, there was no correlation between CVAI and characteristics of initial presentation or history of trauma for either NAT ( p -values: 0.359 and 0.250, respectively) or neglect groups ( p -values: 0.116 and 0.770, respectively).

Conclusion  While there are many limitations to this study, our results suggest that abused children are no more likely to have history of DP than the general population, and the degree of DP is not associated with severity of trauma history or initial presentation. We hope the results of this study promote future investigations for unique and subtle predictive factors of child abuse/neglect.

Safety and efficacy of independent allied healthcare professionals in the assessment and management of plagiocephaly patients

BACKGROUND

The incidence of positional plagiocephaly has increased significantly over the last two decades, which has caused a service delivery challenge for pediatric neurosurgeons. As a potential solution to the long waitlists for abnormal head shape, a plagiocephaly clinic was established at BC Children's Hospital (BCCH) in Vancouver, Canada. This clinic was supervised by an occupational therapist who had been trained by a neurosurgeon to independently assess and manage patients with a referring diagnosis of positional plagiocephaly.

OBJECTIVES

To determine the efficiency of the BCCH Plagiocephaly Clinic in the management of positional plagiocephaly patients and to investigate the clinic's ability to appropriately identify and refer patients with craniosynostosis to pediatric neurosurgeons for further assessment.

METHODS

A retrospective chart review was conducted to identify patients who were assessed and managed at the BCCH Plagiocephaly Clinic between 2008 and 2014. Data on patient demographics, head shape measurements, and treatment recommendations were collected, and the BC Children's neurosurgical database was cross-referenced to identify craniosynostosis cases missed by the Plagiocephaly Clinic. A descriptive analysis of the clinic's average wait times, severity of the patients' plagiocephaly, and recommended interventions was conducted. In addition, the sensitivity and specificity of the clinic's ability to appropriately refer craniosynostosis patients to pediatric neurosurgery were calculated.

RESULTS

Of 1752 patients seen in the BC Children's Plagiocephaly Clinic between 2008 and 2014, 66% of patients received counseling about repositioning, 34% were referred for head banding, 19% were referred to physiotherapy for torticollis, and 1.4% were referred to the BC Children's Pediatric Neurosurgery Clinic for suspicion of craniosynostosis. The mean time from referral to first assessment by the Plagiocephaly Clinic was 41 days, and time from referral by the plagiocephaly clinic to diagnosis of craniosynostosis by a pediatric neurosurgeon was 8 days. Pediatric neurosurgeons requested imaging for 6 of the referred patients (25% ). The sensitivity and specificity of the plagiocephaly clinic for referral of craniosynostosis patients to the Pediatric Neurosurgery Clinic were 100 and 99%, respectively.

CONCLUSION

The BC Children's Plagiocephaly Clinic is efficient and safe for the initial evaluation and treatment of patients with positional plagiocephaly. The clinic's model decreases wait times, appropriately manages patients with positional plagiocephaly, screens for craniosynostosis with high sensitivity and specificity, and takes pressure off outpatient neurosurgical clinics. This model for assessment of plagiocephaly could be considered in other medical centers.

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

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

Craniofacial Asymmetry from One to Three Years of Age: A Prospective Cohort Study with 3D Imaging

Deformational plagiocephaly (DP) is considered a risk factor for facial asymmetry. This cohort-based, prospective, follow-up study used three-dimensional (3D) stereophotogrammetry to assess the development of facial asymmetry in a normal birth cohort and to investigate the impact of DP on facial asymmetry for the age range of one to three years. The study sample consisted of 75 children: 35 girls (47%) and 40 (53%) boys recruited from Oulu University Hospital. A total of 23 (31%) subjects had a history of DP in infancy. 3D facial images were obtained at the mean (SD) age of 1.01 (0.04) year old at T1 and 3.02 (0.14) years old at T2. To determine facial asymmetry, both landmark-based and surface-based facial symmetry methods were used. As measured with the surface-based methods, upper facial symmetry improved from T1 to T2 (p < 0.05). As measured with the landmark-based methods, facial symmetry improved on the upper and lower jaw from T1 to T2 (p < 0.05). The asymmetric effect of DP on the upper parts of the face tends to correct spontaneously during growth. Results indicate that previous DP does not seem to transfer to facial or occlusal asymmetry at the age of three years old.

Plagiocephaly after Neonatal Developmental Dysplasia of the Hip at School Age

Developmental dysplasia of the hip (DDH) may require early abduction treatment with infants sleeping on their back for the first few months of life. As sleeping on back is known to cause deformational plagiocephaly, we assessed school age children treated for dislocation or subluxation of the hip-joint in infancy. Plagiocephaly was analyzed by using cephalic index (CI) and oblique cranial length ratio (OCLR) as anthropometric measurements from 2D digital vertex view photographs. Six of the 58 (10.3%) DDH children and only one of the 62 (1.6%) control children had plagiocephaly (p = 0.041). Furthermore, cross bite was found in 14 (24.1%) of the DDH children and in 7 (10.3%) of the control children. Developmental dysplasia of the hip in infancy was associated with cranial asymmetries and malocclusions at school age. Preventive measures should be implemented.

A 3D Follow-Up Study of Cranial Asymmetry from Early Infancy to Toddler Age after Preterm versus Term Birth

Preterm infants are at higher risk for both symmetrical and asymmetrical head molding. This study involved 3D stereophotogrammetry to assess the cranial growth, molding, and incidence of deformational plagiocephaly (DP) in preterm children compared to term born children. Thirty-four preterm infants and 34 term born controls were enrolled in this study from Oulu University Hospital, Finland. Three-dimensional head images were obtained at the age of 2–4 months (T1), 5–7 months (T2), 11–13 months (T3), and 2.5–3 years (T4) from the term equivalent age (TEA). There was no statistically significant difference in oblique cranial length ratio (OCLR), cephalic index (CI), or weighted asymmetry score (wAS) between the two groups. Occipital flattening, defined by flatness score (FS) was statistically significantly greater in the preterm group than in the term group at T1–T4 (p < 0.05). In both groups, OCLR improved gradually over time. There were no instances, in either group, of severe DP and no moderate DP after T2. Results indicate that DP affects preterm and full-term children almost equally during the first three years of life, and cranial asymmetry resolves at a similar rate in both preterm and term groups after three months of corrected age. Preterm infants present with more occipital flattening than full-term 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.

Nonsynostotic plagiocephaly: a child health care intervention in Skaraborg, Sweden

Background

The aim was to evaluate the intervention’s effect on prevention and reversal of nonsynostotic plagiocephaly.

Methods

Thirty-eight intervention group nurses were educated about nonsynostotic plagiocephaly and asked to follow guidelines; 18 control group nurses were not. In a longitudinal single-blinded clinical intervention, parents brought infants to well-child visits according to the national schedule. Cranial shape was assessed in 176 intervention and 92 control group infants at 2-, 4-, and 12-month visits.

Results

Asymmetry at two months reversed by four months four times more often in intervention than control subgroup infants (OR = 4.07, p = 0.02) when adjusted for parent awareness of written information from their nurse. Asymmetry at two months reversed by 12 months fivefold when parents were aware of written information (OR = 0.19, p = 0.04). The risk for persistent asymmetry at 12 months was lower for intervention than control group infants (RR = 0.35, p = 0.03). Of infants with no asymmetry at two months, 25% in intervention and 22% in control group developed brachycephaly.

Conclusions

The intervention contributed to early reversal and reducing infants’ risk for persistent asymmetry. Parents’ awareness of written information contributed to reversal. Preventing brachycephaly was difficult. Further research is needed.

Electronic supplementary material

The online version of this article (10.1186/s12887-019-1405-y) contains supplementary material, which is available to authorized users.

Cord serum 25-hydroxyvitamin D is not associated with cranial anthropometrics in infants up to 6 months of age. An Odense Child Cohort study

Skull changes are poorly described in vitamin D insufficiency [serum 25-hydroxyvitamin D (s-25(OH)D) 25-50 nmol/L]. We aimed to investigate factors associated with cranial anthropometrics in infants, especially s-25(OH)D. In infants 2.5-6 months old from the Odense Child Cohort, associations between cord and pregnancy s-25(OH)D and anterior fontanel area (n = 765), head circumference (HC, n = 1776) and head shape (n = 1527) were investigated along with other factors. Age was corrected for preterm birth. The mean (SD) s-25(OH)D in early pregnancy was 65.97 (21.33) nmol/L; late pregnancy 78.61 (27.18) nmol/L; and cord 47.1 (21.7) nmol/L. At median (IQR) age 3.7 (2.5-5.9) months, the fontanel area was 225 (0-1690) mm², and mean (SD) HC was 41.5 (1.5) cm. Asymmetric/flat head shape was present in 846 infants (55.3%). No associations were found between cord, early or late pregnancy s-25(OH)D and any cranial measure by univariate or adjusted analysis. Among significant, independent associations in multivariate analysis, fontanel area was associated inversely with gestational age (GA); HC was associated directly with GA, maternal pre-pregnancy overweight and caesarean section and inversely with smoking; and asymmetrical head shape showed a novel association with male sex: adjusted OR = 1.54 (95% CI 1.25; 1.89), p < 0.001. Other associations with asymmetrical head shape included parity 3+, gestational age and maternal age 30+ years (all protective). In conclusion, neither pregnancy nor cord s-25(OH)D was associated with fontanel size, HC or asymmetrical head shape despite a high prevalence of cord s-25(OH)D < 50 nmol/L. Lower GA was associated with larger fontanel size, lower HC and asymmetrical head shape, and boys more frequently had asymmetrical head shape, probably due to heavier heads.

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

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

CONCLUSIONS

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

Deformational plagiocephaly: The case for an evolutionary mismatch

Lay Summary: In industrialized societies some babies develop flattening of the back part of their head. It is thought that this comes from sleeping supine, which has been shown to be the safest option for babies. However, this explanation cannot be correct from an evolutionary standpoint: why should safe sleep come at the cost of a misshaped head?

Babies in industrialized societies are generally healthy. The medical problems they may be afflicted with are usually well understood. Deformational plagiocephaly presents a notable exception. In many industrialized countries, one in six babies shows posterior flattening of the skull—a feature noteworthy from an evolutionary perspective as the well rounded cranium is part of the ‘Kindchenschema’ evolved to secure care for the infant. It is commonly held that the deformation of the posterior cranium occurs as a consequence of the supine sleep position, now advocated as the safest sleep position for babies by medical experts. This explanation, however, does not fare well in the light of evolutionary theory: why should safe sleep come at the cost of a social handicap? Here, we present an alternative hypothesis that is grounded on evolutionary mismatch theory and exemplifies how evolutionary reasoning can help clarify medical conditions relevant to today’s public health.

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.

Use of black-bone MRI in the diagnosis of the patients with posterior plagiocephaly

PURPOSE

Ionising radiation exposure is especially harmful to brain development. The purpose of this study was to evaluate whether black-bone (BB) magnetic resonance imaging (MRI), a non-ionising imaging method, offers an alternative to ionising imaging methods such as computed tomography (CT) in the examination of cranial deformities.

METHODS

From 2012 to 2014, a total of 408 children were referred to the Craniofacial Centre at the Helsinki University Hospital for further examination due to flatness of the posterior skull. Fifteen of these patients required further diagnostic imaging. To avoid ionising radiation, we used an MRI protocol that included sequences for evaluation of both brain anatomy and skull bone and sutures by BB-MRI. A semi-automatic skull segmentation algorithm was developed to facilitate the visualisation. Two patients with scaphocephaly were included in the study to confirm the ability to differentiate synostosis with BB-MRI.

RESULTS

We obtained informative 3D images using BB-MRI. Seven patients (7/15, 46.7%) had plagiocephaly on the right side and seven on the left side (7/15, 46.7%). One patient (1/15, 6.7%) had symmetric posterior flatness affecting both sides. Neither structural nor signal-intensity alterations of the brain were detected in visual analysis.

CONCLUSION

BB-MRI provides an alternative to CT when imaging craniofacial deformities. BB-MRI provides not only high-quality 3D-reconstructed imaging of the bony structures and sutures but also information on brain structure in one imaging session. With further development, this method could replace ionising radiation-based methods in analysing deformities of the skull.

Impact of Parent Practices of Infant Positioning on Head Orientation Profile and Development of Positional Plagiocephaly in Healthy Term Infants

AIMS

The influence of infant positioning on the development of head orientation and plagiocephaly is not clear. This study explored the relationship between infant body and head positioning, with the development of asymmetrical head orientation and/or positional plagiocephaly. Methods: Clinician measurement of head orientation profile and parent-reported infant positioning data were collected for 94 healthy term infants at 3, 6, and 9 weeks of age. Plagiocephaly was measured at 9 weeks with the modified Cranial Vault Asymmetry Index.

RESULTS

More severe plagiocephaly was associated with longer supine-sleep-maximum (p = 0.001) and longer supine-lying-total (p = 0.014) at 6 weeks. Prone positioning was not associated with plagiocephaly. Parent-reported head asymmetry during awake and sleep time at 3 weeks identified infants with clinician-measured head asymmetry at 9 weeks. Better symmetry in head turning was associated with more side-lying-total time by 9 weeks (p = 0.013).

CONCLUSIONS

Our results showed that infant positioning is associated with early head orientation and plagiocephaly development. Early parent-reported asymmetry during awake and sleep time is an important indicator for the need for professional assessment and advice. A Plagiocephaly Prevention Strategy and Plagiocephaly Screening Pathway are provided for clinicians and parents.

Common Manual Therapy Practices in the Netherlands for Infants With Upper Cervical Dysfunction: A Prospective Cohort Study

OBJECTIVE

The purpose of this study was to describe common clinical practices of manual therapists (MTs) in the Netherlands for infants with indications of upper cervical dysfunction (UCD).

METHODS

A prospective observational cohort study was conducted to gain insight into characteristics, reasons for seeking care, and common clinical practice for infants (<27 weeks) with indications of UCD, referred to MTs. Pre- and posttreatment self-reported questionnaires were used to collect data from parents and MTs. Parents reported on infant characteristics and perceived effect of treatment. Manual therapists reported on diagnostics, therapeutic procedures, and outcomes.

RESULTS

Between 2006 and 2007, data regarding 307 referred infants (mean age: 11.2 weeks) were collected by parents and 42 MTs. The most frequent reasons for seeking care were positional preference, restlessness, and/or abnormal head position. Manual therapists observed active, spontaneous, and provoked mobility and passive upper cervical mobility. Of the 307 infants, 295 were diagnosed with UCD based on positive outcomes on the flexion-rotation test and/or lateral flexion test. After treatment with mobilization techniques, positive outcomes on the flexion-rotation test decreased from 78.8% to 6.8%. For the lateral flexion test, the positive outcomes decreased from 91.5% to 6.2%. All parents perceived positive treatment effects. No serious adverse events were reported during this study.

CONCLUSIONS

This is the first study to describe common clinical practice for infants referred for manual therapy. Infants with UCD were treated mainly with upper cervical mobilization techniques, and the greatest perceived effect was observed after approximately 2 treatment sessions.

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.

Analysis of the correlation between deformational plagiocephaly and neurodevelopmental delay

BACKGROUND

Deformational plagiocephaly (DP) refers to cranial asymmetry resulting from uneven external forces. A strong association exists between DP and developmental delay. We investigated the effect of DP severity on developmental delay.

METHODS

Between 2010 and 2016, data from 155 patients with DP were reviewed retrospectively. Two indices were used to evaluate the deformation quantitatively: cranial index (CI) and cranial vault asymmetry index (CVAI). The Bayley Scales of Infant Development-II was used to evaluate the neurodevelopment of patients.

RESULTS

According to the CI of the study population, 2 patients showed scaphocephaly, 12 showed mesocephaly, and 141 showed brachycephaly. For CVAI, 10 patients showed values of <3.5, 10 patients showed mild deformity (3.5-6.25), 27 patients showed moderate deformity (6.25-8.75), and 108 patients showed severe deformity. The means of the mental development index (MDI) and psychomotor development index (PDI) were 91.69 ± 16.8 and 92.28 ± 17.59, respectively; after the exclusion of patients with confounding factors, the values were 96.26 and 92.9, respectively. The Spearman correlation coefficients between MDI and CI and CVAI were -0.019662 and 0.118916, respectively, whereas for PDI, the values were -0.195428 and -0.012386, respectively.

CONCLUSIONS

There was a statistically significant neurodevelopmental delay in patients with DP. However, accelerated neurodevelopment was also encountered in many patients. MDI was found to be more affected by multiple confounding factors than PDI, whereas PDI was only affected by congenital anomalies. There was no definitive relationship between the severity of DP and the degree of developmental delay in our study group.