Objective Outcome Analysis of Soft Shell Helmet Therapy in the Treatment of Deformational Plagiocephaly

Effects of adherence to treatment for repositioning therapy, physical therapy, and cranial remolding orthoses in infants with cranial deformation

Deformational head shapes are most often treated through repositioning therapy (RT) and/or cranial remolding orthotic (CRO) treatment. However, there is conflicting evidence about the effectiveness of each method, and treatment compliance is suspected to affect treatment effectiveness. This study examines participant adherence with these treatment methods and explores if cranial correction is related to compliance. This study also reviews effects of developmental milestones and explores other potential impacts on compliance. A total of 45 infants with cranial deformation were consented and those with congenital muscular torticollis (CMT) concurrently received physical therapy. Infants were followed from 2 to 12 months of age and initially assigned to RT. Caregivers continued RT until the head shape corrected, caregivers chose to switch to a CRO, or infants turned 12 months of age. All participants were scheduled for a final visit at 12 months of age. Throughout treatment, caregiver surveys were used to examine compliance and developmental milestones. Results show promise for future investigation into the relationship between treatment modalities and adherence with treatment for deformational head shapes. Our findings provide preliminary support that treatment adherence may be linked with treatment success and concurrent enrollment in physical therapy increases patient compliance.

Ultrasonography as first line imaging for the diagnosis of positional plagiocephaly

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Rethinking Farkas: Updating Cephalic Index Norms in a Large, Diverse Population

BACKGROUND

Cephalic index, the ratio of head width to length, is one normative indicator used by insurers to derive criteria for plagiocephaly helmet authorization. Current norms were established by a small sample of white children in the 1987 Farkas and Munro data set. This study establishes updated cephalic index values for infants and children in a large, diverse patient population.

METHODS

Children aged 0 to 3 months, 3 to 6 months, 9 to 12 months, 2 to 3 years, and 12 to 14 years were recruited at their well-child appointment. Cephalic index was calculated for each age group and compared to previously established norms.

RESULTS

Eight hundred seventy patients met inclusion criteria. The means for boys and girls between 0 and 6 months were 83.5 (n = 155, SD 6.01) and 83.5 (n = 191, SD 5.80), respectively. Established means for boys and girls between 0 and 6 months were 74.4 (n = 38, SD 5.2) and 74.3 (n = 49, SD 6.1), respectively. The difference between norms is highly statistically significant (p < 0.0001). For this age range, insurance criteria for a helmet is >83.7 for boys and >82.7 for girls. Using previous norms, 74 boys (44.6 percent) and 104 girls (54.5 percent) would meet criteria for a helmet under current guidelines.

CONCLUSIONS

The mean cephalic index of children has changed. The reasons could include diversifying populations in the United States and the introduction of the Back to Sleep campaign. Over 50 percent of children may inappropriately meet criteria for a helmet based on prior norms. Updating norms could change the definition of plagiocephaly for a helmet orthosis.

Head Orthosis Therapy in Positional Plagiocephaly: Influence of Age and Severity of Asymmetry on Effect and Duration of Therapy

BACKGROUND

Only a few studies investigating the optimal time point at which to start orthotic treatment for deformational plagiocephaly take into account the severity of skull asymmetry. The present study performs a three-dimensional analysis of the effects of age and severity of asymmetry on the final outcome.

METHODS

A total of 144 patients with deformational plagiocephaly treated by molding orthosis were examined and divided into three age groups (group I, <24 weeks; group II, ≥24 to <32 weeks; and group III, ≥32 weeks) and two severity levels (mild to moderate, 30-degree cranial vault asymmetry ≥3 mm to ≤12 mm; and moderate to severe, 30-degree cranial vault asymmetry >12 mm). The extent of the reduction of asymmetry was analyzed using three-dimensional stereophotogrammetry.

RESULTS

Therapy with molding orthosis led to a significant reduction in asymmetry in all defined age groups. Efficacy of reduction decreased with increasing age. Successful treatment (cranial vault asymmetry index <3.5 percent) was achieved in 83, 69, and 40 percent of patients with mild to moderate asymmetry in groups I, II, and III, respectively; and in 50, 30, and 7 percent of patients with moderate to severe asymmetry in groups I, II, and III, respectively. The average duration of treatment increased from 18.6 weeks to 25.3 weeks (age groups I and III).

CONCLUSION

Age at the beginning of treatment and severity of asymmetry have a definite impact on the duration and effectiveness of molding orthosis therapy.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, II.

Relationship between starting age of cranial-remolding-orthosis therapy and effectiveness of treatment in children with deformational plagiocephaly

PURPOSE

The aim of this study was to investigate the optimal age for starting cranial-remolding-orthosis therapy in children with deformational plagiocephaly.

METHODS

Medical records of 310 patients with deformational plagiocephaly were retrospectively reviewed and the initial and final cranial vault asymmetry index (CVAI), age when starting therapy, duration of therapy, mean change of CVAI, improvement rate, and treatment success were analyzed. We compared outcomes according to the groups divided by ages starting therapy.

RESULTS

There were no significant differences in improvement rate and duration of cranial-remolding-orthosis therapy among patients starting therapy at the age of 3, 4, and 5 months. However, when starting therapy after the age of 6 months, the rates of CVAI improvement were significantly lower and the duration of therapy was significantly increased.

CONCLUSION

Considering the spontaneous resolution effect according to the head growth nature, the age 5 month is the optimal period to start cranial-remolding-orthosis therapy for deformational plagiocephaly.

Guidelines: Congress of Neurological Surgeons Systematic Review and Evidence-Based Guideline for the Diagnosis of Patients With Positional Plagiocephaly: The Role of Imaging

BACKGROUND

No evidence-based guidelines exist for the imaging of patients with positional plagiocephaly.

OBJECTIVE

The objective of this systematic review and evidence-based guideline is to answer the question, Is imaging necessary for infants with positional plagiocephaly to make a diagnosis?

METHODS

The National Library of Medicine Medline database and the Cochrane Library were queried with the use of MeSH headings and key words relevant to imaging as a means to diagnose plagiocephaly. Abstracts were reviewed, and an evidentiary table was assembled summarizing the studies and the quality of evidence (Classes I-III). Based on the quality of the literature, a recommendation was rendered (Level I, II, or III).

RESULTS

A total of 42 full-text articles were selected for review. Of these, 10 were eliminated; thus, 32 full-text were manuscripts selected. There was no Class I evidence, but 2 Class II and 30 Class III studies were included. Three-dimensional cranial topographical imaging, ultrasound, skull x-rays, computed tomography, and magnetic resonance imaging were investigated.

CONCLUSION

Clinical examination is most often sufficient to diagnose plagiocephaly (quality, Class III; strength, Level III). Within the limits of this systematic review, the evidence suggests that imaging is rarely necessary and should be reserved for cases in which the clinical examination is equivocal. Many of the imaging studies were not designed to address the diagnostic utility of the imaging modality, and authors were actually assessing the utility of the imaging in longitudinal follow-up, not initial diagnosis. For this reason, some of the studies reviewed were downgraded in Level of Evidence. When needed, 3-dimensional cranial topographical photo, skull x-rays, or ultrasound imaging is almost always sufficient for definitive diagnosis. Computed tomography scanning should not be used to diagnose plagiocephaly, but it may be necessary to rule out craniosynostosis. The full guidelines document can be located at https://www.cns.org/guidelines/guidelines-management-patients-positional-plagiocephaly/Chapter_2.

Long-term outcomes in treatment of deformational plagiocephaly and brachycephaly using helmet therapy and repositioning: a longitudinal cohort study

OBJECTIVES

Deformational plagiocephaly and/or brachycephaly (DPB) is a misshapen head presenting at birth or shortly thereafter, caused by extrinsic forces on an infant's malleable cranium. There are two treatment methods available for DPB: helmeting and repositioning. Little is known about the long-term outcomes of these two treatment options. The purpose of this study was to examine children who received helmeting or repositioning therapy for DPB as infants and compare the long-term head shape outcomes of the two groups.

METHODS

A longitudinal cohort study design was used to evaluate change in head shape of the two groups. One hundred children (50 helmeted, 50 repositioned) were initially evaluated at 6 months or younger for DPB. Anthropometric skull measurements taken as infants before treatment were compared with measurements taken for this study. Inclusion criteria included initial clinic visit at age 6 months or younger, evaluation by the same practitioner, and current age 2-10 years. Cephalic index and cranial vault asymmetry were calculated based on caliper measurements.

RESULTS

Data from 100 children were evaluated for this study. Significant differences between the treatment groups in the mean change in cephalic index (p = 0.003) and cranial vault asymmetry (p < 0.001) were found; the children that used helmet therapy demonstrated greater improvement.

CONCLUSIONS

This is one of the larger published long-term outcome studies comparing children that used helmets and repositioning to treat their DPB as infants. The data suggest that infants will have more improvement in head shape with a helmet than with repositioning.

Nonsynostotic Cranial Deformity: A Six-Month Matched-Pair Photogrammetric Comparison of Treated and Untreated Infants

Objective

To photogrammetrically objectify changes in nonsynostotic craniofacial deformity in orthotically treated versus untreated infants.

Design

A statistical retrospective pairwise comparison of two respective three-dimensional (3D) photo scans of 80 children performed in a 6-month time lag.

Patients

Two comparable samples of children (40 treated, 40 untreated) with nonsynostotic cranial deformity.

Interventions

Respective 3D photo scans were matched using Cranioform Analytics 4.0 software.

Main Outcome Measures

Median change of 30° Cranial Vault Asymmetry Index (CVAI), modified CVAI (CVAImod), Cranial Index (CI), and posterior symmetry ratio (PSR).

Results

We found an improvement in Δ30° CVAI by 3.3% (treated) and by 1.31% (untreated), respectively. CVAImod improved by 3.46% in the treated group and by 1.55% in the untreated group. CI improved by 4.41% in the treated group and by 3.68% in the untreated group, and PSR improved by 0.71 in the treated group and 0.49 in the untreated group. Although improvement of cranial asymmetry was higher in those children treated with an individual molding orthosis, we could not document a statistically significant difference between the two groups.

Conclusions

Helmet therapy may be less appropriate for the correction of brachycephaly than for cranial asymmetry. Nonsynostotic cranial deformity shows some spontaneous correction. Photogrammetry presents an accurate method to objectify craniofacial changes in early infancy.

Positional plagiocephaly: experience with a passive orthotic mattress

Positional plagiocephaly (deformational or occipital plagiocephaly) is the most common head-shape deformity, which is presented to specialist craniofacial units. The aim of management is to reduce pressure on the affected area in the expectation that brain growth will drive normalization of the head shape. Current management includes a variety of protocols based on repositioning advice or helmet orthotics. The aim of this study is to document changes in head shape associated with use of a passive orthotic mattress for the management of positional plagiocephaly of a series of 30 patients at Alder Hey Children's Hospital between April 2008 and June 2010. Cranial vault asymmetry was assessed before treatment and was classified into mild, moderate, or severe plagiocephaly. Follow-up demonstrated a significant improvement in cranial vault asymmetry in those treated with the passive orthotic mattress.

Outcome analysis after helmet therapy using 3D photogrammetry in patients with deformational plagiocephaly: the role of root mean square

Deformational plagiocephaly (DP) is a multifactorial non-synostotic cranial deformity with a reported incidence as high as 1 in 7 infants in North America. Treatment options have focused on non-operative interventions including head repositioning and the use of an orthotic helmet device. Previous studies have used linear and two dimensional outcome measures to assess changes in cranial symmetry after helmet therapy. Our objective was to demonstrate improvement in head shape after treatment with a cranial molding helmet by using Root Mean Square (RMS), a measure unique to 3D photogrammetry, which takes into account both changes in volume and shape over time. Three dimensional photographs were obtained before and after molding helmet treatment in 40 infants (4-10 months old) with deformational plagiocephaly. Anatomical reference planes and measurements were recorded using the 3dMD Vultus(®) analysis software. RMS was used to quantify symmetry by superimposing left and right quadrants and calculating the mean value of aggregate distances between surfaces. Over 95% of the patients demonstrated an improvement in symmetry with helmet therapy. Furthermore, when the sample of infants was divided into two treatment subgroups, a statistically significant correlation was found between the age at the beginning of treatment and the change in the RMS value. When helmet therapy was started before 7 months of age a greater improvement in symmetry was seen. This work represents application of the technique of RMS analysis to demonstrate the efficacy of treatment of deformational plagiocephaly with a cranial molding helmet.

The incidence of positional plagiocephaly: a cohort study

OBJECTIVE

The objective of this study was to estimate the incidence of positional plagiocephaly in infants 7 to 12 weeks of age who attend the 2-month well-child clinic in Calgary, Alberta, Canada.

METHODS

A prospective cohort design was used to recruit 440 healthy full-term infants (born at ≥37 weeks of gestation) who presented at 2-month well-child clinics for public health nursing services (eg, immunization) in the city of Calgary, Alberta. The study was completed in 4 community health centers (CHCs) from July to September 2010. The CHCs were selected based on their location, each CHC representing 1 quadrant of the city. Argenta's (2004) plagiocephaly assessment tool was used to identify the presence or absence of plagiocephaly.

RESULTS

Of the 440 infants assessed, 205 were observed to have some form of plagiocephaly. The incidence of plagiocephaly in infants at 7 to 12 weeks of age was estimated to be 46.6%. Of all infants with plagiocephaly, 63.2% were affected on the right side and 78.3% had a mild form.

CONCLUSIONS

To our knowledge, this is the first population-based study to investigate the incidence of positional plagiocephaly using 4 community-based data collection sites. Future studies are required to corroborate the findings of our study. Research is required to assess the incidence of plagiocephaly using Argenta's plagiocephaly assessment tool across more CHCs and to assess prevalence at different infant age groups. The utility of using Argenta's plagiocephaly assessment tool by public health nurses and/or family physicians needs to be established.

Treatment of deformational plagiocephaly and torticollis using a weight distribution ring: a report of three cases

Plagiocephaly, from the Greek 'plagios' (slanting) and 'kephale' (head), refers to a condition of an infant's head deformation by forces acting upon a malleable cranium. Marked plagiocephaly causes distress and stigma towards the baby and their family and has knock-on effects with craniofacial abnormalities, visual-field defects and delay in motor skills, and may also cause developmental difficulties. Current treatment methods have multiple drawbacks. This small, illustrated case series presents a novel, cost-effective, practical first-line treatment using a horseshoe-shaped gel head ring to redistribute pressure, allowing uniform growth and reshaping. Our early experience suggests that this method represents an effective treatment option with promising results so far.

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.

Prevalence of Positional Plagiocephaly in Teens Born after the “Back to Sleep” Campaign

Objectives. To determine the prevalence of positional plagiocephaly and brachycephaly in teenagers born after the “Back to Sleep” campaign but before orthotic helmet treatment became widely available and to provide long-term outcomes data on those children with plagiocephaly who were not treated with remolding therapy.

Study Design. Cross-sectional analysis.

Setting. Local high schools in the Minneapolis–St Paul Metro area.

Subjects and Methods. Subjects were selected if they attended participating high schools and were born after the Back to Sleep campaign began. Skull measurements, including transcranial diameter, length, and width, were taken. Overall facial appearance was inspected for any apparent abnormal characteristics. Cranial vault asymmetry and cephalic index were calculated for each participant. Plagiocephaly was diagnosed if cranial vault asymmetry was >1 cm. Brachycephaly was diagnosed if the cephalic index was >0.90.

Results. There were 1045 participants, ranging from 12 to 17 years old, with an average age of 15.7 years. The prevalence of plagiocephaly was 1.1%. The prevalence of brachycephaly was 1.0%. The overall prevalence of a deformational cranial abnormality was 2.0%. Of those who met diagnostic criteria of plagiocephaly or brachycephaly, 38.1% were noted to have abnormal facial characteristics.

Conclusions. The prevalence of plagiocephaly and brachycephaly in teenagers is significantly lower than the 20% to 48% prevalence found in infants in previous studies, suggesting most children will outgrow the condition without intervention. Additional studies are needed to determine which patients might benefit from treatment and which will likely have resolution without intervention, since treating all infants who meet criteria results in significant overtreatment.

Exploring the impact of osteopathic treatment on cranial asymmetries associated with nonsynostotic plagiocephaly in infants

OBJECTIVES

To document the evolution of cranial asymmetries in infants with signs of nonsynostotic occipital plagiocephaly (NSOP) who were to undergo a course of four osteopathic treatments (in addition to the standard positioning recommendations) as well as to determine the feasibility of using this methodology to conduct a randomized clinical trial investigating the impact of osteopathic intervention for infants with NSOP.

DESIGN

Pilot clinical standardization project using pre-post design in which 12 infants participated. Ten infants presented an initial Oblique Diameter Difference Index (ODDI) over 104% and five of them had an initial moderate to severe Cranial Vault Asymmetry (CVA) (over 12mm).

INTERVENTIONS

Infants received four osteopathic treatments at 2-week intervals.

MAIN OUTCOME MEASURES

Anthropometric, plagiocephalometric as well as qualitative measures were administered pre-intervention (T1), during the third treatment (T2) and two weeks after the fourth treatment (T3).

RESULTS

Participants showed a significant decrease in CVA (p=0.02), Skull Base Asymmetry (SBA) (p=0.01), Trans-Cranial Vault Asymmetry (TCVA) (p<0.003) between the first and third evaluations.

CONCLUSIONS

These clinical findings support the hypothesis that osteopathic treatments contribute to the improvement of cranial asymmetries in infants younger than 6.5 months old presenting with NSOP characteristics.

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

OBJECT

Deformational plagiocephaly (DP) is the leading cause of head shape abnormalities in infants. Treatment options include conservative measures and cranial molding. Pediatric neurosurgeons and craniofacial plastic surgeons have yet to agree on an ideal therapy, and no definable standards exist for initiating treatment with helmets. Furthermore, there may be differences between specialties in their perceptions of DP severity and need for helmet therapy.

METHODS

Requests to participate in a web-based questionnaire were sent to diplomates of the American Board of Pediatric Neurological Surgery and US and Canadian members of the Pediatric Joint Section of the American Association of Neurological Surgeons and the Congress of Neurological Surgeons and the American Cleft Palate-Craniofacial Association. Questions focused on educational background; practice setting; volume of DP patients; preferences for evaluation, treatment, follow-up; and incentives or deterrents to treat with helmet therapy. Six examples of varying degrees of DP were presented to delineate treatment preferences.

RESULTS

Requests were sent to 302 neurosurgeons and 470 plastic surgeons, and responses were received from 71 neurosurgeons (24%) and 64 plastic surgeons (14%). The following responses represented the greatest variations between specialties: 1) 8% of neurosurgeons and 26% of plastic surgeons strongly agreed with the statement that helmet therapy is more beneficial than conservative therapy (p < 0.01); and 2) 25% of neurosurgeons and 58% of plastic surgeons would treat moderate to severe DP with helmets (p < 0.01).

CONCLUSIONS

Survey responses suggest that neurosurgeons are less likely to prescribe helmet therapy for DP than plastic surgeons. Parents of children with DP are faced with a costly treatment decision that may be influenced more strongly by referral and physician bias than medical evidence.

Molding therapy of positional plagiocephaly: subjective outcome and quality of life

To evaluate quality of life (QOL) and parental satisfaction in children diagnosed and treated with molding helmet therapy (MHT) for positional plagiocephaly, a retrospective chart research was performed on 166 children who had visited the craniofacial outpatient clinic in the University Hospital of Maastricht between 2002 and 2003. Two questionnaires were sent to parents of these children. The first was used to measure QOL (TAPQOL questionnaire) and was related to a healthy control group. The second evaluated parents' satisfaction concerning the shape of their children's head before and after treatment. One hundred forty-two children were diagnosed with positional plagiocephaly. The group consisted of 111 boys (78.2%) and 31 girls (21.8%). Ninety-eight patients were treated by MHT and 44 had no treatment. Indications for treatment were an ARGENTA classification of type 3 or worse and subjective rating of head shape by the parents. Parents of all children treated with MHT were sent both questionnaires. Forty-six parents (response rate 47%) returned the questionnaires. This group consisted of 39 boys and eight girls. The healthy control group consisted of 251 children between the ages of 1 and 5 years and was used to validate the questionnaire in a previous study. There were no significant differences in QOL scores between the healthy control group and children treated with molding helmet therapy (P > 0.05). Parents gave an average rating of 3.6 before therapy and 7.5 after therapy, a difference of 3.9. Of 46 parents whose children had MHT, only two would not repeat or recommend this therapy. Reasons were unsatisfying result and, in one case, serious pressure spots with hair loss. The population in this study was similar to other studies. Results showed no difference in QOL between treated children and a healthy control group. This study showed that MHT in children with severe positional plagiocephaly does not have long-term adverse effects on QOL. Differences in subjective rating show that MHT has a good result on head shape. A 96% satisfaction rate shows that it is a pleasant therapy and gives a satisfying result.

Comparison of a modifiable cranial cup versus repositioning and cervical stretching for the early correction of deformational posterior plagiocephaly

BACKGROUND

Deformational occipital flattening is the most common cause of abnormal head shape. Current treatment calls for repositioning and cervical stretching in infants younger than 5 months. The authors assessed the effectiveness of a modifiable cranial cup compared to repositioning and cervical stretching to correct early deformational plagiocephaly.

METHODS

This nonrandomized, prospective clinical trial used historical controls. The treatment and control groups consisted of infants, younger than 4 months, referred for deformational posterior plagiocephaly. The control children were managed by repositioning and cervical stretching exercises. An adjustable concave cranial cup was used in the treated group. Infants were examined at the initial and final visits by a single examiner. Calvarial asymmetry was measured using a large cranial caliper. Active head rotation and degree of rotational asymmetry were estimated to the nearest 10 degrees.

RESULTS

There were no statistically significant differences between the control (n = 23) and treatment groups (n = 24) with respect to gestational age at birth, age at initial visit, initial head rotational asymmetry, initial transcranial difference, final head rotational asymmetry, and age at final evaluation. Mean time between initial and final evaluation was 56.3 days for the treatment group and 61.6 days for the control group. The mean transcranial difference decreased from 11.2 to 3.5 mm in the treatment group, and from 9.0 to 8.0 mm in the control group (p = 0.000).

CONCLUSION

The cranial cup, a modifiable concave resting surface, is significantly more effective than repositioning and physical therapy for correcting early deformational plagiocephaly.

Long-term outcome of infants with positional occipital plagiocephaly

BACKGROUND

Despite much interest in positional (deformational) plagiocephaly, the natural history is unclear. The purpose of this study was to determine cosmetic and developmental outcomes at a minimum of 5 years of age in children diagnosed in infancy with positional plagiocephaly (PP) and the impact of cranial orthotic use.

METHODS

A questionnaire survey was sent to parents of children diagnosed with PP in infancy and now aged more than 5 years. A retrospective review of the child's clinic chart was performed of consenting families, and prospective follow-up was done when families agreed to return for assessment.

RESULTS

Of 278 eligible children with plagiocephaly, questionnaires were completed by 65 parents, and 27 brought their child for assessment. Participants and nonparticipants were similar. Cranial orthoses were used in 18 of 65 children. Parents perceived the cosmetic appearance of their child as "very abnormal" in 2, "mildly abnormal" in 25, and "normal" in 38. Residual asymmetry was noted by parents in 58%, but only 21% were concerned about appearance. In the last year, 7.7% of children commented about asymmetry of head, and 4.6% were teased occasionally. Thirty-three percent had received learning assistance, and 14% were in a special class. Long-term outcomes, as perceived by the parent or child, were no different between children with and without orthosis use.

CONCLUSIONS

The results allow better counselling of parents about outcome of infants with PP, reducing anxiety, and allowing more rational selection of management modality.

Comparison of Infant Head Shape Changes in Deformational Plagiocephaly Following Treatment With a Cranial Remolding Orthosis Using a Noninvasive Laser Shape Digitizer

Deformational Plagiocephaly (DP) is a multi-planar deformity of the cranium occurring either pre-or postnatally in infants. In the last decade, the incidence of DP has increased substantially due to a number of factors, including supine sleeping positioning to reduce Sudden Infant Death Syndrome and the use of child carriers that increase supine positioning. Clinical questions persist about which children should be treated for DP and how to intervene, questions that are difficult to answer without accurate documentation of three-dimensional (3-D) head shape. This study explored a method for quantifying head shape and used that method to evaluate the success of orthotic treatment. Two hundred twenty-four infants who were diagnosed with DP received either a cranial remolding orthosis or a repositioning program with no orthotic intervention. Data from 25 head shape variables were collected using a noninvasive laser shape digitizer. Only variables attributable to growth showed significant differences in the control population, while the treatment population showed significant differences in pre-and post-treatment values for all variables. The study identified four variables as particularly important in assessing the head shape of infants with plagiocephaly: the cranial vault asymmetry index, radial symmetry index, posterior symmetry ratio, and overall symmetry ratio. Ninety-six percent or more of subjects in the treatment group showed improvement in each variable. These data document the utility of a 3-D scanning device and the effectiveness of treatment with a cranial remolding orthosis.

Soft-helmet skull remodeling in canine models: intracranial volume unchanged by compensatory skull growth

OBJECT

Habitual sleeping positions in infants can produce occipital plagiocephaly, which causes strabismus as well as skull and facial asymmetry. This condition can be managed using a hard helmet, but maintaining an infant in such a device is often intolerable. The authors studied whether the shape of a young canine skull could reform while inside a soft helmet and whether intracranial volume would be preserved by the compensatory growth of the skull.

METHODS

The authors tracked the head sizes of 14 1-week-old beagles who wore long, soft helmets (study group) and seven beagles who did not (control group). From these measurements, the intracranial volume in each beagle was calculated. All crania were also studied radiologically by using plain skull radiography, computerized tomography (CT), and magnetic resonance (MR) imaging. The crania of all 14 beagles who wore soft helmets quickly adapted, resulting in a narrow, long head only 2 weeks into the experiment. This configuration continued to develop throughout the 7-week experimental period. At 8 weeks of age, animals in the study group showed no significantly different alteration in calculated intracranial volumes (p > 0.05). It is interesting that the helmet-treated animals initially underwent a paradoxical increase in intracranial volume growth. No structural difference in their brains was evident from CT or MR imaging findings, nor was there any functional disability.

CONCLUSIONS

Intracranial volume can be preserved by the compensatory growth of the skull during successful remodeling of the developing skull achieved using a soft helmet.

Quantifying Positional Plagiocephaly

The treatment of positional plagiocephaly is controversial. A confounding factor is the lack of a proven clinically viable measure to quantify severity and change in plagiocephaly. The use of anthropometric measurements is one proposed method. In this study, the reliability and validity for this method of measurement were investigated. Two clinicians independently recorded caliper measurements of cranial vault asymmetry (CVA) for infants referred for plagiocephaly or torticollis, and an unbiased observer recorded visual analysis scores during the same visit. CVA scores were assigned into three predetermined severity categories (normal CVA < 3 mm, mild/moderate CVA <or= 12 mm, moderate/severe CVA > 12 mm). CVA measurements and visual analysis scores were recorded for 71 and 54 infants, respectively. Intrarater reliability was established (kappa = 0.98, kappa = 0.99), but inter-rater reliability was not (kappa = 0.42). In addition, the inter-rater reliability for the severity categories based upon these measures was poor (kappa = 0.28) and failed to correlate to the visual analysis (kappa = 0.31). Development of a stable and meaningful measurement system for the extent of plagiocephaly is needed to allow scientific studies of the natural history of plagiocephaly and effectiveness of interventions.

Impacting infant head shapes

Infant sleep position impacts the development of head shape. Changes in infant sleep position, specifically the movement toward supine sleep, have led to a redefinition of normal head shape for infants in the United States. Historically, a dolichocephalic (elongated) head shape was the norm. Currently the norm has changed to a more brachycephalic (shorter and broader) shape. Since the American Academy of Pediatrics' Back to Sleep Campaign, the incidence of positional plagiocephaly has increased dramatically with a concurrent rise in the incidence of torticollis. Infants who require newborn intensive care, particularly premature infants, are more prone to positional plagiocephaly and dolichocephaly. Both can be prevented or minimized by proper positioning. The infant with an abnormal head shape requires careful evaluation; treatment varies according to the etiology. Craniosynostosis, a less common but pathological etiology for plagiocephaly, should be considered in the diagnostic process. Successful treatment of positional plagiocephaly and dolichocephaly includes systematic positioning changes to overcome the mechanical forces of repetitive positioning, physical and/or occupational therapy to treat underlying muscle or developmental challenges, and in some cases, molding helmet therapy.

Neurodevelopmental implications of "deformational" plagiocephaly

Over the past decade there has been a dramatic increase in referrals to specialty clinics, craniofacial centers, plastic surgeons, and neurosurgeons for assessment and treatment of deformational plagiocephaly (DP). Though considered a medically benign condition, preliminary reports suggest that DP may be associated with developmental problems. However, mechanisms to account for this association have not been hypothesized or empirically tested. Although treatment justifications often center on prevention of atypical appearance, little is known about the cosmetic outcomes of treated and untreated children. In this review we hypothesize different etiological pathways linking DP with neurodevelopment (e.g., environmental positioning limitations with and without underlying CNS pathology). We outline directions for research on incidence and prevalence, developmental outcomes, sex differences, determinants of treatment participation, and craniofacial appearance. Despite the paucity of existing research, preliminary findings suggest that children with this condition should be screened and monitored for developmental delays or deficits, as we await more conclusive information from future studies.