Comparison of perceptions and treatment practices between neurosurgeons and plastic surgeons for infants with deformational plagiocephaly

Diagnosis and treatment of positional plagiocephaly

Positional plagiocephaly is increasing in infants. Positional plagiocephaly is an asymmetric deformation of skull due to various reasons; first birth, assisted labor, multiple pregnancy, prematurity, congenital muscular torticollis and position of head. Positional plagiocephaly can mostly be diagnosed clinically and by physical examinations. The simplest way to assess the severity of plagiocephaly is to use a diagonal caliper during physical examination, which measures the difference between the diagonal lengths on each side of the head. Plagiocephaly can be treated surgically or conservatively. Positional plagiocephaly, which is not accompanied by craniosynostosis, is treated conservatively. Conservative treatments involve a variety of treatments, such as change of positions, physiotherapy, massage therapy, and helmet therapy. Systematic approaches to clinical examination, diagnosis and treatment of positional plagiocephaly can be necessary and the age-appropriate treatment is recommended for patients with positional plagiocephaly.

Head orthosis therapy in positional plagiocephaly: longitudinal 3D-investigation of long-term outcomes, compared with untreated infants and with a control group

Background

As there are very few long-term studies on the effects of head orthosis on deformational plagiocephaly (DP), we investigated the outcomes of patients, including facial symmetry and dental occlusion.

Methods

Forty-five infants with DP [cranial vault asymmetry index (CVAI) > 3.5 per cent] were divided into two groups: one treated with head orthosis (32 infants) and another without (13 infants). Another group without head asymmetry (CVAI ≤ 3.5 per cent) served as control. Using 3D-stereophotogrammetry, cranial asymmetry was analysed using symmetry-related variables [CVAI, posterior cranial asymmetry index (PCAI), and ear offset]. Data acquisition was performed before (T1) and at the end of treatment (T2), and at the age of 4 years (T3) for the treated group and at T1 and T3 for the remaining groups. Parameters of facial symmetry and dental occlusion were assessed at T3 for infants with DP.

Results

Symmetry-related variables (∆T1-T3) improved significantly more in the treated than the control group, whereas these parameters did not differ significantly between the untreated and control group. Comparing the treated and untreated groups between T1 and T3, the reduction in the asymmetry at the treated group was significantly higher for the CVAI and PCAI. In follow-up, the untreated group showed higher incidences of facial asymmetries than the treated group. Seventy-five per cent of all lateral crossbites found in patients with DP were contralateral to the posterior flattening.

Limitations

Due to ethical reasons, the investigation is a non-randomized study. Parameters of facial symmetry were only assed for the treated and untreated groups.

Conclusion

Head orthosis therapy in patients with DP leads to significantly better long-term outcomes. Facial asymmetries are more frequent in patients with DP who do not receive this treatment.

Long-term satisfaction and parental decision making about treatment of deformational plagiocephaly

The incidence of deformational plagiocephaly (DP) has increased greatly during the last 2 decades since the recommendation of supine sleeping. Currently, there are 2 treatment options for DP, helmet therapy and repositioning therapy. This research investigated factors that influenced parental decision making about treatment choice and long-term satisfaction with head shape. A retrospective chart review identified 1660 children, now aged 2 to 10 years, seen in the DP clinic meeting inclusion criteria. Questionnaires were mailed to all eligible families. Four-hundred fifty-six completed questionnaires were returned. The questionnaires evaluated demographics of the family, factors that influenced treatment choice, and satisfaction with current head shape. Most of the respondents had white (93%) and male (70%) children. The mothers' mean age at the time of childbirth was 31 years; most of the mothers had a college degree or higher (77%) and household incomes of more than $76,000 (52.6%). Fifteen factors were used to evaluate which ones were significant in influencing parental treatment choice. Severity of the DP and time off work for follow-up appointments were the only 2 factors identified that significantly affected treatment choice. More parents who used helmet therapy reported that they were satisfied with their child's long-term head shape and would choose the same treatment again (P = 0.002) compared with those who used repositioning therapy.

Positional cranial deformity--the parents' point of view

The parents' point of view regarding positional cranial deformities and helmet therapy has not been the subject of scientific interest yet. However, carer acceptance is a key factor for therapeutic success. We therefore investigated parental perception. The parents of 218 infants were included in a telephone survey; 122 children had undergone helmet therapy and 96 had not. Satisfaction with the outcome, treatment-associated problems, and parental stress were investigated using a structured questionnaire. The great majority (90.8%) of caregivers were satisfied with the outcome, regardless of whether or not helmet therapy was used. Retrospectively, 76% of the parents of infants who had not undergone helmet therapy would decide against helmet therapy again. Therapy was either temporarily stopped (27.0%) or terminated (4.9%) in 31.9% of infants treated with a helmet. Major problems were sweating (51.1%) and skin lacerations (30.9%). The parents indicated minor (54.9%) or even great (25.4%) personal strain. Conflict with others (38.5%), stress for the child (30.3%), and a financial burden (36.9%) were mentioned most frequently. There appear to be more parental problems than expected associated with helmet therapy. Medical experts should take this into consideration. The indication for a helmet should be evaluated critically and the potential parental burdens should be addressed during counselling.

Parents' decision for helmet therapy in infants with skull deformation

PURPOSE

Helmet therapy is regularly prescribed in infants with positional skull deformation. Evidence on the effectiveness is lacking, which complicates decision making. This study aims to assess the relation between parents' decision for treatment of skull deformation in their infant and their level of anxiety, decisional conflict, expectations of treatment effect, perceived severity of deformation and perceived side effects.

METHODS

Parents of 5-month-old infants with skull deformation were invited to participate in a survey. Data collection included background characteristics, anthropometric assessment, parent-reported outcomes, decision for treatment (helmet therapy or awaiting natural course), decisional conflict scale and questions about perceived (side) effects of helmet therapy. Factors significantly correlated with treatment decision (p < 0.1) were tested in a multiple logistic regression analysis.

RESULTS

The results of 186 respondents were included in the analysis. Parental satisfaction with their infant's head shape (adjusted odds ratio (aOR) 0.2; 95 % confidence interval (CI) 0.1 to 0.4), expected effect of helmet therapy compared to natural course (aOR 13.4; 95 % CI 5.0 to 36.1) and decision uncertainty (aOR 1.0; 95 % CI 0.9 to 1.0; p = .03) were related to the decision for helmet therapy in infants with skull deformation.

CONCLUSION

With the outcomes of this study, we can better understand parental decision-making for elective 'normalizing' treatments in children, such as helmet therapy in infants with skull deformation. Health care professionals should address the parents' perception of the severity of skull deformation and their expectations of helmet therapy. Furthermore, they can support parents in decision-making by balancing medical information with parents' expectations, values and beliefs.

Efficacy of passive helmet therapy for deformational plagiocephaly: report of 1050 cases

OBJECT

There has been a tremendous increase in the incidence of deformational plagiocephaly in children throughout the world. Therapeutic options include observation, active counterpositioning, external orthotics, and surgery. The current treatment in the US is highly debated, but it typically includes external orthotic helmets in patients with moderate to severe plagiocephaly presenting between 4 and 10 months of age or in children with significant comorbidities limiting passive (no-pressure) therapy. The present study was designed to evaluate 3 key issues: 1) the accuracy of the Argenta classification in defining a progressive degree of severity, 2) identification of an upper age limit when treatment is no longer effective, and 3) the effectiveness of an off-the-shelf prefabricated helmet in correcting deformational plagiocephaly.

METHODS

An institutional review board-approved retrospective study was conducted of all patients at the authors' clinic in whom deformational plagiocephaly was assessed using the Argenta classification system over a 6-year period; the patients underwent helmet therapy, and a minimum of 3 clinic visits were recorded. Inclusion criteria consisted of an Argenta Type II-V plagiocephalic deformity. Patients' conditions were categorized both by severity of the deformity and by patients' age at presentation. Statistical analysis was conducted using survival analysis.

RESULTS

There were 1050 patients included in the study. Patients with Type III, IV, and V plagiocephaly required progressively longer for deformity correction to be achieved than patients with Type II plagiocephaly (53%, 75%, and 81% longer, respectively [p < 0.0001]). This finding verified that the Argenta stratification indicated a progressive severity of deformity. No statistically significant difference in the time to correction was noted among the different age categories, which suggests that the previously held upper time limit for correction may be inaccurate. An overall correction rate to Type I plagiocephaly of 81.6% was achieved irrespective of severity and degree of the original deformity. This suggests that an inexpensive off-the-shelf molding helmet is highly effective and that expensive custom-fitted orthoses may not be necessary. The patients in the older age group (> 12 months) did not have a statistically significant longer interval to correction than the patients in the youngest age group (< 3 months). The mean length of follow-up was 6.3 months.

CONCLUSIONS

Patients treated with passive helmet therapy in the older age group (> 12 months) had an improvement in skull shape within the same treatment interval as the patients in the younger age group (< 3 months). This study supports the use of passive helmet therapy for improvement in deformational plagiocephaly in infants from birth to 18 months of age and verifies the stratification of degree of deformity used in the Argenta classification system.

A comparison of costs associated with endoscope-assisted craniectomy versus open cranial vault repair for infants with sagittal synostosis

OBJECT

The surgical management of infants with sagittal synostosis has traditionally relied on open cranial vault remodeling (CVR) techniques; however, minimally invasive technologies, including endoscope-assisted craniectomy (EAC) repair followed by helmet therapy (HT, EAC+HT), is increasingly used to treat various forms of craniosynostosis during the 1st year of life. In this study the authors determined the costs associated with EAC+HT in comparison with those for CVR.

METHODS

The authors performed a retrospective case-control analysis of 21 children who had undergone CVR and 21 who had undergone EAC+HT. Eligibility criteria included an age less than 1 year and at least 1 year of clinical follow-up data. Financial and clinical records were reviewed for data related to length of hospital stay and transfusion rates as well as costs associated with physician, hospital, and outpatient clinic visits.

RESULTS

The average age of patients who underwent CVR was 6.8 months compared with 3.1 months for those who underwent EAC+HT. Patients who underwent EAC+HT most often required the use of 2 helmets (76.5%), infrequently required a third helmet (13.3%), and averaged 1.8 clinic visits in the first 90 days after surgery. Endoscope-assisted craniectomy plus HT was associated with shorter hospital stays (mean 1.10 vs 4.67 days for CVR, p < 0.0001), a decreased rate of blood transfusions (9.5% vs 100% for CVR, p < 0.0001), and a decreased operative time (81.1 vs 165.8 minutes for CVR, p < 0.0001). The overall cost of EAC+HT, accounting for hospital charges, professional and helmet fees, and clinic visits, was also lower than that of CVR ($37,255.99 vs $56,990.46, respectively, p < 0.0001).

CONCLUSIONS

Endoscope-assisted craniectomy plus HT is a less costly surgical option for patients than CVR. In addition, EAC+HT was associated with a lower utilization of perioperative resources. Theses findings suggest that EAC+HT for infants with sagittal synostosis may be a cost-effective first-line surgical option.

Comparison of helmet therapy and counter positioning for deformational plagiocephaly

OBJECTIVE

To compare effectiveness on correcting cranial and ear asymmetry between helmet therapy and counter positioning for deformational plagiocephaly (DP).

METHODS

Retrospective data of children diagnosed with DP who visited our clinic from November 2010 to October 2012 were reviewed. Subjects ≤10 months of age who showed ≥10 mm of diagonal difference were included for analysis. For DP treatment, information on both helmet therapy and counter positioning was given and either of the two was chosen by each family. Head circumference, cranial asymmetry measurements including diagonal difference, cranial vault asymmetry index, radial symmetry index, and ear shift were obtained by 3-dimensional head-surface laser scan at the time of initiation and termination of therapy.

RESULTS

Twenty-seven subjects were included: 21 had helmet therapy and 6 underwent counter positioning. There was no significant difference of baseline characteristics, head circumferences and cranial asymmetry measurements at the initiation of therapy. The mean duration of therapy was 4.30±1.27 months in the helmet therapy group and 4.08±0.95 months in the counter positioning group (p=0.770). While cranial asymmetry measurements improved in both groups, significantly more improvement was observed with helmet therapy. There was no significant difference of the head circumference growth between the two groups at the end of therapy.

CONCLUSION

Helmet therapy resulted in more favorable outcomes in correcting cranial and ear asymmetry than counter positioning on moderate to severe DP without compromising head growth.

Complications associated with molding helmet therapy for positional plagiocephaly: a review

Molding helmet therapy is a widely accepted treatment for positional plagiocephaly that is generally considered to be low risk. Multiple large outcome studies have shown good results, but adverse events are rarely reported. The literature on helmet therapy was reviewed to clarify the clinical experience with associated complications. Although significant complications were extremely rare, there was a large degree of variability in detection of lesser problems such as minor skin irritation. Patients with a primarily brachycephalic morphology may be at higher risk for poorly fitting orthoses. Most reported complications are minor and self-limited. Maintenance of good helmet hygiene appears to be the most effective strategy for reducing or eliminating complications.

Helmet treatment of deformational plagiocephaly: the relationship between age at initiation and rate of correction

BACKGROUND

The purpose of this study was to evaluate the relationship between age at initiation of helmet therapy for deformational plagiocephaly and the rate of correction.

METHODS

Infants treated for deformational plagiocephaly with a helmet orthosis between 2009 and 2010 were included. Patients were stratified prospectively by the age at which treatment was initiated: group 1, younger than 20 weeks (n = 26); group 2, 20 to 23.9 weeks (n = 59); group 3, 24 to 27.9 weeks (n = 82); group 4, 28 to 31.9 weeks (n = 62); group 5, 32 to 35.9 weeks (n = 45); group 6, 36 to 40 weeks (n = 29), and group 7, older than 40 weeks (n = 43). Pretreatment and posttreatment calvarial asymmetry was measured using direct anthropometry and reported as a transcranial difference.

RESULTS

Three hundred forty-six infants were included; initial transcranial difference was equivalent on all paired-group comparisons. Duration of helmet therapy positively correlated with age at initiation (r = 0.89, p < 0.05). The rate of change in transcranial difference correlated negatively with age at treatment onset (r = -0.88, p < 0.05): group 1, 0.93 mm/week; group 2, 0.64 mm/week; group 3, 0.59 mm/week; group 4, 0.56 mm/week; group 5, 0.41 mm/week; group 6, 0.42 mm/week; and group 7, 0.42 mm/week). At the conclusion of therapy, all groups had improved calvarial symmetry, albeit less completely in groups 6 and 7.

CONCLUSIONS

The correction rate of plagiocephaly with helmet therapy decreases with increasing infant age; after 32 weeks, there is a slow and relatively constant rate of change. Improvement can still be achieved in infants older than 12 months.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, II.

Deformational plagiocephaly and orthotic treatment: indications and limitations

PURPOSE

As the incidence of deformational plagiocephaly (DP) has risen, so has the demand on clinicians to make appropriate treatment recommendations. While knowledge of risk factors and natural history continue to evolve, there is uncertainty and controversy regarding intervention approaches. The purpose of this report is to review current treatment approaches for DP, in particular the use of orthotic helmets.

METHODS

A narrative literature review was conducted to summarize current evidence supporting preventative measures and re-positional and orthotic interventions.

RESULTS

When started early at under 2 months of age, positional efforts and 'tummy time' can be effective in preventing and improving DP, but these strategies need to be better promoted to caregivers. The timing, severity and parental concerns as indicators for orthotic treatment are reviewed. Limitations discussed include high cost, lower level of evidence and poor understanding of long-term outcomes and caregiving implications.

CONCLUSION

For optimal outcome, current evidence supports use of repositioning in young infants and start of orthotic helmet treatment for infants with significant DP at 4-6 months. Further research is needed to better understand the parameters for use (stratified by age and severity), long-term outcomes and natural history and the impact on caregiving, as well as the cultural significance of head shape.

HElmet therapy Assessment in infants with Deformed Skulls (HEADS): protocol for a randomised controlled trial

BACKGROUND

In The Netherlands, helmet therapy is a commonly used treatment in infants with skull deformation (deformational plagiocephaly or deformational brachycephaly). However, evidence of the effectiveness of this treatment remains lacking. The HEADS study (HElmet therapy Assessment in Deformed Skulls) aims to determine the effects and costs of helmet therapy compared to no helmet therapy in infants with moderate to severe skull deformation.

METHODS/DESIGN

Pragmatic randomised controlled trial (RCT) nested in a cohort study. The cohort study included infants with a positional preference and/or skull deformation at two to four months (first assessment). At 5 months of age, all children were assessed again and infants meeting the criteria for helmet therapy were asked to participate in the RCT. Participants were randomly allocated to either helmet therapy or no helmet therapy. Parents of eligible infants that do not agree with enrolment in the RCT were invited to stay enrolled for follow up in a non-randomisedrandomised controlled trial (nRCT); they were then free to make the decision to start helmet therapy or not. Follow-up assessments took place at 8, 12 and 24 months of age. The main outcome will be head shape at 24 months that is measured using plagiocephalometry. Secondary outcomes will be satisfaction of parents and professionals with the appearance of the child, parental concerns about the future, anxiety level and satisfaction with the treatment, motor development and quality of life of the infant. Finally, compliance and costs will also be determined.

DISCUSSION

HEADS will be the first study presenting data from an RCT on the effectiveness of helmet therapy. Outcomes will be important for affected children and their parents, health care professionals and future treatment policies. Our findings are likely to influence the reimbursement policies of health insurance companies.Besides these health outcomes, we will be able to address several methodological questions, e.g. do participants in an RCT represent the eligible target population and do outcomes of the RCT differ from outcomes found in the nRCT?

TRIAL REGISTRATION

ISRCTN18473161.