Significant Factors Influencing the Effectiveness of Cranial Remolding Orthoses in Infants With Deformational Plagiocephaly

Infants with deformational plagiocephaly may be indicated for a cranial remolding orthosis (CRO) depending on the severity of deformation. Studies have found torticollis and prematurity to be risk factors for the development of deformational plagiocephaly and indicate younger infants have faster and greater correction. However, clinical decisions about which infants should be recommended for CRO treatment differ among healthcare providers and insurance coverage criteria vary. In order to provide insight into treatment recommendations, this study aims to examine the influence of 4 specific factors on CRO treatment time and the infant's resultant posttreatment head shape. Results indicate that presenting age, presenting severity, and the presence of torticollis significantly influence treatment duration. Presenting age and severity were found to significantly influence final head shape. The presence of prematurity was not found to be significant when infants were categorized by their corrected postpartum ages.

Positional Skull Deformities

BACKGROUND

Especially in the first 6 months of life, skull deformities manifesting as a uni- or bilateral flattening of the occiput often give rise to questions of differential diagnosis and potential treatment. In this review, the authors summarize the current understanding of risk factors for this condition, and the current state of the relevant diagnostic assessment and options for treatment.

METHODS

The recommendations given in this selective review of the literature are based on current studies and on existing guidelines on the prevention of sudden infant death, the recommendations of the German Society for Pediatric Neurology (Deutsche Gesellschaft für Neuropädiatrie), and the American guidelines on the treatment of positional plagiocephaly in infancy.

RESULTS

Pre-, peri-, and postnatal risk factors can contribute to the development of positional skull deformities. These deformities can be diagnosed and classified on the basis of their clinical features, supplemented in unclear cases by ultrasonography of the cranial sutures. The putative relationship between positional skull deformities and developmental delay is currently debated. The main preventive and therapeutic measure is parent education to foster correct positioning habits (turning of the infant to the less favored side; prone positioning on occasion when awake) and beneficial stimulation of the infant (to promote lying on the less favored side). If the range of motion of the head is limited, physiotherapy is an effective additional measure. In severe or refractory cases, a skull orthosis (splint) may be useful.

CONCLUSION

The parents of children with positional skull deformities should be comprehensively informed about the necessary preventive and therapeutic measures. Treatment should be initiated early and provided in graded fashion, according to the degree of severity of the problem. Parental concern about the deformity should not be allowed to lead to a rejection of the reasonable recommendation for a supine sleeping position.

Association of Positional Plagiocephaly and Developmental Delay Within a Primary Care Network

OBJECTIVE

Previous research has suggested an association between plagiocephaly and developmental delay. However, study samples drawn from children seen in subspecialty clinics increase the potential for selection and referral bias. Our study evaluates the association between plagiocephaly and developmental delay and the timing of these diagnoses in a primary care setting, where plagiocephaly is commonly diagnosed and managed.

METHODS

Our retrospective analysis used electronic medical record data from 45 primary care sites within a children's health system from 1999 to 2017, including children aged 0 to 5 years with diagnoses determined by physician diagnosis codes at primary care visits. Children were classified in the plagiocephaly group if diagnosis occurred by 12 months of age. Primary outcome was any developmental delay. Pearson χ2 test, Fisher exact test, and logistic regression analyses were conducted, with multivariable models adjusted for sex, race, ethnicity, insurance, prematurity status (22-36 weeks' gestation), primary care sites, birth year, and diagnoses of abnormal tone and torticollis.

RESULTS

Of 77,108 patients seen by 12 months, 2315 (3.0%) were diagnosed with plagiocephaly, with an increase in diagnosis prevalence over the study time frame. Plagiocephaly was independently associated with an increased odds of any developmental delay diagnosis (adjusted odds ratio 1.50, 95% confidence interval 1.32-1.70). The diagnosis of plagiocephaly was recorded before the diagnosis of developmental delay in most cases when both diagnoses were present (374 of 404, 92.6%).

CONCLUSION

Data from a large primary care cohort demonstrate an association between plagiocephaly and developmental delay, affirming findings in previous subspecialty literature.

Denominator of Cranial Vault Asymmetry Index: Choosing Between Longer and Shorter Diagonal Lengths

Since it was proposed in this journal in 2001, the cranial vault asymmetry index (CVAI) has been an important parameter for assessing cranial shape. However, different publications currently use different variables in the denominator of the CVAI formula. We thus investigated the use of long and short diagonal lengths as variables in the denominator of the CVAI formula. We searched the databases of PubMed, Google Scholar, and Scopus for articles published between 2016 and 2022 that cited the original work article of CVAI. Articles were included if they were written in English and if the denominator of the CVAI formula was specified. For multiple articles by the same author, only the most recent article was included. In total, 30 articles were included; 10 articles used the longer diagonal length as the denominator and 20 articles used the shorter diagonal length. No uniform trend was observed by a country or journal of publication. Application of the CVAI formula using different denominators yielded interchangeable results, and the resulting values had only negligible differences clinically. However, it would be necessary to create a standard formula for using the CVAI as a parameter for reporting cranial shape assessments consistently.

Subjective perception of craniofacial growth asymmetries in patients with deformational plagiocephaly

OBJECTIVES

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

CLINICAL RELEVANCE

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

Medical Malpractice Litigations Involving Infant Craniosynostosis and Deformational Plagiocephaly in the United States

OBJECTIVE

To identify characteristics of malpractice litigations involving skull deformity in infants (craniosynostosis and deformational plagiocephaly).

DESIGN

Retrospective review of all lawsuits with jury verdicts or settlements involving infant skull deformity as the primary diagnosis using the Westlaw Legal Database.

SETTING

United States.

PATIENTS, PARTICIPANTS

Plaintiffs with skull deformity as the primary diagnosis.

MAIN OUTCOME MEASURES

Litigation outcome and indemnity payment amount.

RESULTS

From 1990 to 2019, 9 cases involving infant skull deformity met our inclusion/exclusion criteria. Among these cases, 8 (88.9%) cases resulted in indemnity payments to plaintiffs, totaling $30,430,000. Failure to diagnose (n = 4, 44.4%) and surgical negligence (n = 3, 33.3%) were the most common reasons for litigations.

CONCLUSIONS

There were a small number of malpractice lawsuits involving infant skull deformity over three decades. When cases go to court, physicians and hospitals have a high likelihood of judgment against them, frequently resulting in high indemnity payments.

Nonsyndromic Craniofacial Disorders

We describe the investigation and management of select pediatric craniofacial disorders their recent advances. Positional plagiocephaly: The incidence of positional plagiocephaly has increased since the institution of the "safe to sleep" campaign to reduce sudden infant death syndrome. Positional plagiocephaly may be associated with underlying developmental delay. Nonsyndromic craniosynostosis: Treatment of nonsyndromic craniosynostosis depends on the age of the patient and the suture involved. Pediatric skull lesions: Management of skull lesions depends on histologic diagnosis. Some benign skull lesions are managed conservatively, whereas erosive and malignant lesions may require surgical excision, radiotherapy, chemotherapy, or multimodality treatment.

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

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

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

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

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

Positional Plagiocephaly Side and Neurodevelopmental Delay: Study on 408 Infants

OBJECTIVE

Provide data on a cross-sectional study of neurodevelopmental delays in positional plagiocephaly (PP) based on severity and flattening side on early childhood patients.

METHODS

Neurodevelopment of 408 PP in patients with an age range of 3 to 59 months was assessed with Battelle Developmental Inventory (BDI) tests during and after their cranial orthotic treatment. Data obtained were compared with the cranial anthropometric measurements taken the same day the test was made, and results were segregated by flattening side, grouped by diagnosis and severity, segmented by age group, and split by sex.

RESULTS

From 3983 patients with positional skull deformities and simple craniosynostosis, 526 patients accepted to participate and took a total of 1261 BDI tests. Premature, patients with neurological diseases, cranial malformations, tests taken when positional skull deformity was corrected, and tests without plagiocephaly were excluded. The resulting database was made of 408 PP patients (300 boys and 108 girls) and 883 BDI tests (345 with left-side plagiocephaly and 538 with right-side plagiocephaly). Significant neurodevelopmental delay in more than one BDI domain on left-side plagiocephaly tests is observed in 76.4% of female and 92.2% of male patients and on right-side plagiocephaly tests in 75.5% of female and 95.5% of male patients. Neurodevelopmental delay difference between flattening sides, when both plagiocephaly sides presented significant delays, ranges from 0.2 to 3 months (BDI domain fine motor, Cephalic Index range ≥85 <100; BDI communication, age group 18-23).

CONCLUSION

Neurological delay may vary depending on plagiocephaly side, thus when evaluating plagiocephaly patients the flattening side should be noted.