A randomized controlled trial of positioning treatments in infants with positional head shape deformities

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.

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.

Analysis of cranial type characteristics in term infants: a multi-center study

Background

Positional head deformity (PHD) is defined as a change in the shape of an infant’s skull due to an external force. In certain cases, it can lead to cosmetic deformities or even neurological issues due to its impact on the developing nervous system. Therefore, we conducted this study to investigate the incidence and characteristics of PHD in term infants in China and preliminarily establish a localized diagnostic reference standard.

Methods

Overall, 4456 term infants from three medical institutions in Chongqing were and divided and analyzed according to their age. Cranial vault asymmetry (CVA) and cephalic index (CI) were calculated in all infants. The current international diagnostic criteria were used to understand PHD incidence and analyze the CVA and CI distribution.

Results

According to the current international standards, the total detection rate of PHD in Chongqing’s term infants was 81.5%, with brachycephaly alone being the most frequent (39.4%), followed by brachycephaly with plagiocephaly (34.8%) and plagiocephaly alone (6.2%). The detection rates of dolichocephaly were low: alone, 0.9% and combined with plagiocephaly, 0.2%. According to age, plagiocephaly (44.5%) and brachycephaly (82.0%) were the most frequent in the 2-3-month group. The 75th/90th/97th and 3rd/10th/25th/75th/90th/97th percentiles of CVA and CIs were 0.4/0.7/1.0 and 76.4/78.8/82.3/91.1/94.6/99.2%, respectively.

Conclusions

According to the current international standards, the PHD detection rate among term infants in Chongqing was high. Therefore, a new diagnostic standard for Chinese infants was proposed where CVA ≥ 0.4 cm indicates plagiocephaly, CI ≥ 91% indicates brachycephaly, and CI ≤ 82% indicates dolichocephaly.

Interrater and Intrarater Reliability of Cranial Anthropometric Measurements in Infants with Positional Plagiocephaly

(1) Background: anthropometric measurements with calipers are used to objectify cranial asymmetry in positional plagiocephaly but there is controversy regarding the reliability of different methodologies. Purpose: to analyze the interrater and intrarater reliability of direct anthropometric measurements with caliper on defined craniofacial references in infants with positional plagiocephaly. (2) Methods: 62 subjects (<28 weeks), with a difference of at least 5 mm between cranial diagonal diameters. Maximal cranial circumference, length and width and diagonal cranial diameters were measured. Intrarater (2 measurements) and interrater (2 raters) reliability was analyzed. (3) Results: intra- and interrater reliability of the maximal cranial length and width and right cranial diagonal was excellent: intraclass correlation coefficient (ICC) > 0.9. Intrarater and interrater reliability for the left cranial diagonal was excellent: ICC > 0.9 and difference in agreement in the Bland-Altman plot 0.0 mm, respectively. Intrarater and interrater reliability for the maximal cranial circumference was good: differences in agreement in Bland-Altman plots: intra: −0.03 cm; inter: −0.12 cm. (4) Conclusions: anthropometric measurements in a sample of infants with moderate positional plagiocephaly have shown excellent intra- and interrater reliability for maximal cranial length, maximal cranial width, and right and left cranial diagonals, and good intra- and interrater reliability in maximal cranial circumference measurement.

The Effects of Helmet Therapy Relative to the Size of the Anterior Fontanelle in Nonsynostotic Plagiocephaly: A Retrospective Study

Helmet therapy is an important nonsurgical approach for patients with nonsynostotic plagiocephaly, but its effectiveness may depend on certain anatomical features. We retrospectively examined the effects of helmet therapy according to the size of the anterior fontanelle. Two hundred patients with nonsynostotic plagiocephaly who underwent helmet therapy between 2016 and 2018 were included. Data regarding age at treatment onset and treatment duration were collected. Patients were divided into two groups depending on the age at treatment initiation: the 12-23 weeks group and the >23 weeks group. Patients were also divided based on the anterior fontanelle size to analyze the effects of helmet therapy according to the severity of plagiocephaly in each group as the change in the cranial vault asymmetry index (CVAI). Therapeutic effects were evaluated using the cranial vault asymmetry (CVA), CVAI, anterior symmetry ratio, posterior symmetry ratio (PSR), and overall symmetry ratio at baseline and treatment completion. Treatment initiation at age 12-23 weeks resulted in better effects than that after age 24 weeks. There were no sex-dependent differences in therapeutic effects. Greater changes in the CVA, CVAI, and PSR were associated with larger anterior fontanelles. Therefore, the anterior fontanelle size could be a prognostic factor for estimating helmet therapy outcomes.

Feasibility and Safety of the Preemie Orthotic Device to Manage Deformational Plagiocephaly in Extremely Low Birth Weight Infants

BACKGROUND

Premature infants are predisposed to developing deformational plagiocephaly. Deformational plagiocephaly may affect the infant's social well-being and neurobehavioral development.

PURPOSE

This pilot study investigated the feasibility and safety of the preemie orthotic device (POD); a noncommercial, supportive orthotic device to manage deformational plagiocephaly.

METHODS

The setting for this prospective, descriptive, phase 1 clinical trial was 2 urban and 1 suburban neonatal intensive care units that provided care for critically ill premature and term infants. Participants included a convenience sample of 10 premature extremely low-birth-weight infants weighing less than 1 kg. All participants received the experimental treatment with the POD. Time spent on the device with and without the supportive foam insert, provider perception, adverse events, and head shape measurements were collected to assess feasibility and safety of the device.

RESULTS

Participants had a median gestational age of 25.4 weeks and median birth weight of 0.673 kg. The POD was used a median of 21.2 hours per day and the foam insert was used a median of 11.1 hours per day. At enrollment, 1 participant had a normal cranial index compared with 5 participants at study completion. All participants had normal cranial symmetry at study enrollment and completion. No device-related adverse events were reported.

IMPLICATION FOR PRACTICE

The POD was found to be feasible and safe. Staff had favorable responses to the device. Recommendations by nursing staff included enlarging the device to extend its use.

IMPLICATION FOR RESEARCH

Further studies are warranted to assess the POD's effectiveness.

Bridging Exercise Science, Cognitive Psychology, and Medical Practice: Is "Cognitive Fatigue" a Remake of "The Emperor's New Clothes"?

Fatigue is such a multifaceted construct it has sprouted specific research fields and experts in domains as different as exercise physiology, cognitive psychology, human factors and engineering, and medical practice. It lacks a consensus definition: it is an experimental concept, a symptom, a risk, a cause (e.g., of performance decrement) and a consequence (e.g., of sleep deprivation). This fragmentation of knowledge leads to slower dissemination of novel insights, and thus to a poorer research. Indeed, what may seem as a novel result in one field, may very well be old news in another, hence leading to this "innovation" being a scientific equivalent to the emperor's new clothes. The current paper aims to describe the common denominator in the different areas of expertise where fatigue is investigated. Indeed, rather than focusing on the differences in semantics and conceptualization, we hope that identifying common concepts may be inductive of easier multidisciplinary research. Considering the vastness of fatigue research in all areas identified as relevant-cognitive science, exercise physiology, and medical practice, this analysis has not the ambition to be an exhaustive review in all domains. We have reviewed the fatigue concepts and research in these areas and report the ones that are used to describe the proposed common model to be further investigated. The most promising common feature to cognitive science, exercise physiology and clinical practice is the notion of "perceived effort." This allows to account for interindividual differences, as well as for the situational variations in fatigue. It is applicable to both mental and physical constructs. It integrates motivational and emotional dimensions. It overcomes current polemics in various research fields, and it does not draw on any semantic ambiguity. We thus suggest a new model of fatigue and performance, whether this performance is mental or physical; and whether it is in a clinical range or relates to optimal functioning.

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.

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.

[Efficacy of sleep position correction for treating infants with positional plagiocephaly]

OBJECTIVE

To investigate the efficacy of 2-month course of sleeping position correction in the treatment of positional plagiocephaly in infants aged <8 months.

METHODS

A total of 73 infants with positional plagiocephaly between January 2015 and June 2016 were divided into treatment group (n=46) and control group (n=27) according to parents' wishes. The treatment group received sleeping position correction, while the control group received sleep curve mattress. The oblique diameters A and B in the two groups were measured and the cranial vault asymmetry (CVA) was calculated before and after treatment. The severity of positional plagiocephaly based on CVA was compared between the two groups before and after treatment. The Gesell Developmental Scale was used to determine the developmental quotients (DQs) in the motor, adaptive, language, and social domains in the two groups before and after treatment.

RESULTS

Before treatment, there were no significant differences in oblique diameters A and B, CVA, and DQs in the four specific domains between the two groups (P>0.05). After 2 months of treatment, the treatment group had a significantly greater oblique diameter B and a significantly smaller CVA than the control group (P<0.05); there were no significant differences in DQs in the four specific domains between the two groups (P>0.05). After treatment, both groups had significant improvements in oblique diameters A and B, CVA, and DQs in the motor and adaptive domains (P<0.01); moreover, the treatment group showed a significant improvement in the DQs in the social domain (P<0.01). There was no significant difference in the severity of positional plagiocephaly between the two groups before and after treatment (P>0.05).

CONCLUSIONS

For infants with positional plagiocephaly, sleeping position correction has better efficacy and is more convenient and economical than the sleep curve mattress, so it holds promise for clinical application.

Plagiocephaly and Developmental Delay: A Systematic Review

OBJECTIVE

Deformational plagiocephaly (includes plagiocephaly and brachycephaly) is a common pediatric condition. Infants who present with altered head shape often experience developmental delay. It is uncertain how common developmental delay is in infants with plagiocephaly and how sustained this is, when present. This review explores the association between plagiocephaly and developmental delay to guide clinical practice.

STUDY DESIGN

A systematic review was conducted. MEDLINE, EMBASE, CINAHL, and PEDro databases were searched. Data from relevant studies were extracted regarding study: sample, follow-up, design, and findings. Methodological quality of each study was rated using a critical appraisal tool.

RESULTS

The search recovered 1315 articles of which 19 met the inclusion criteria. In the included studies, the children's ages ranged from 3 months to 10 years. Study limitations included selection bias, nonblinding of assessors, and reuse of the same study population for multiple papers. Most papers (11/19) rated "moderate" on methodological quality. A positive association between plagiocephaly and developmental delay was reported in 13 of 19 studies, including 4 of 5 studies with "strong" methodological quality. Delay was more frequently in studies with children ≤24 months of age (9/12 studies) compared with >24 months of age (3/7 studies). Motor delay was the most commonly affected domain reported in high-quality papers (5/5 studies).

CONCLUSION

This review suggests plagiocephaly is a marker of elevated risk of developmental delays. Clinicians should closely monitor infants with plagiocephaly for this. Prompt referral to early intervention services such as physiotherapy may ameliorate motor delays and identify infants with longer term developmental needs.

Cranial shape, size and cervical motion in normal newborns

BACKGROUND

Deformational plagiocephaly (DP) and torticollis are commonly seen in infants and they often co-occur, but little is known of the prevalence and relationship of these conditions in the immediate newborn period. No previous studies focusing on the relationship between cranial shape and cervical motion in newborns can be found.

OBJECTIVES

Determining the incidence rates and characteristics of DP and torticollis and examining the relationship between cervical range of motion (ROM), cranial size and cranial shape in neonates.

METHODS

A single-center, descriptive cross-sectional study including 155 healthy neonates was conducted. Participants were examined during their birth hospitalization. Oblique Cranial Length Ratio (OCLR) and Cephalic Index (CI), indicating cranial asymmetry and shape, were measured from standardized digital photographs with a computer-based cephalometric method. Cervical ROM was measured with goniometry.

RESULTS

7.7% of the newborns had DP and 3.9% had torticollis. 46.4% presented lesser cervical imbalances. DP was associated with gestational diabetes (adjusted OR 5.6; p<0.01) and vacuum assisted delivery (adjusted OR 6.8; p<0.01), but not at all with torticollis. CI correlated strongly with cervical ROM in all directions, while no definite association between cranial asymmetry and cervical motion could be found.

CONCLUSIONS

DP and torticollis are common and minor cervical imbalances very common in normal newborns. Our results support the theory that in most cases neither DP nor torticollis is congenital, but rather develops and worsens synergistically in early infancy. Still, although no direct association between DP and torticollis was found, cranial shape is linked to cervical motion at birth.

Positional plagiocephaly: an analysis of the literature on the effectiveness of current guidelines

OBJECT

Positional plagiocephaly (PP) has been on the rise in recent years. In this review, the authors' aim was to assess the effectiveness of current recommendations to parents on this exceedingly common problem through a comprehensive literature search. Additionally, the current treatment options and the most recent studies on PP are reviewed.

METHODS

A search of the existing literature was conducted to obtain all relevant studies on guidelines, recommendations, parental and clinician practices, and epidemiological aspects.

RESULTS

Although the incidence and risk factors for PP have been well delineated, there continues to be debates on its management and association with developmental delays. Current guidelines and recommendations on prevention set by the American Association of Pediatrics may not be easily followed by both parents and clinicians. There is also evidence that certain populations, including those with lower education, socioeconomic status, and in particular geographic regions may be more affected by the condition. Additionally, the marketing and financial aspects of PP treatments exist and should be addressed.

CONCLUSIONS

Better awareness and education are necessary to inform the population as a whole, although certain populations should be given special attention. Additionally, current guidelines and recommendations can be modified to foster a better grasp of the condition by both parents and clinicians. Adjusting current recommendations, introducing initiatives, and offering elaborate educational campaigns would help deliver these aims. Educating parents on PP as early as possible through clearer guidelines and close monitoring is central to preventing and managing this common condition.

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.

Methods to quantify soft tissue-based cranial growth and treatment outcomes in children: a systematic review

Context

Longitudinal assessment of cranial dimensions of growing children provides healthcare professionals with information about normal and deviating growth as well as treatment outcome.

Objective

To give an overview of soft tissue–based methods for quantitative longitudinal assessment of cranial dimensions in children until age 6 years and to assess the reliability of these methods in studies with good methodological quality.

Data source

PubMed, EMBASE, Cochrane Library, Web of Science, Scopus, and CINAHL were searched. A manual search was performed to check for additional relevant studies.

Study selection

Primary publications on facial growth and treatment outcomes in children younger than age 6 years were included.

Data extraction

Independent data extraction was performed by two observers. A quality assessment instrument was used to determine methodological quality. Methods used in studies with good methodological quality were assessed for reliability expressed as the magnitude of the measurement error and the correlation coefficient between repeated measurements.

Results

In total, 165 studies were included, forming three groups of methods: head circumference anthropometry, direct anthropometry, and 2D photography and 3D imaging techniques (surface laser scanning and stereophotogrammetry). In general, the measurement error was below 2 mm, and correlation coefficients were very good.

Conclusion

Various methods for measuring cranial dimensions have shown to be reliable. Stereophotogrammetry is the most versatile method for quantitative longitudinal assessment of cranial dimensions and shapes in children. However, direct anthropometry continues to be the best method for routine clinical assessments of linear cranial dimensions in growing children until age 6 years.

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.

Posterior plagiocephaly

INTRODUCTION

Asymmetrical cranial vaults resulting from external forces on an infant's head can be caused by abnormal sutural development (synostotic plagiocephaly) or abnormal external forces acting on an intrinsically normal, developing cranium (deformational plagiocephaly).

DISCUSSION

The incidence of posterior plagiocephaly has increased dramatically since the initiation of the "Back to Sleep" campaign against sudden infant death syndrome. The majority of cases are due to deformational plagiocephaly, but rigorous diagnostic evaluation including physical examination and radiological imaging must be undertaken to rule out lambdoid synostosis in extreme or refractory cases.

CONCLUSION

Unique clinical features and radiological examination using computed tomography technology are helpful in confirming the correct cause of posterior plagiocephaly. Plagiocephaly is considered a benign condition, but with the recent increase in cases, new studies have revealed developmental problems associated with cranial vault asymmetries. Treatment of positional/deformational plagiocephaly includes conservative measures, primarily behavior modification, and, in some cases, helmet therapy, whereas lambdoid synostotic plagiocephaly requires surgical intervention, making differentiation of the cause of the asymmetry critical.

Evidence-based care of the child with deformational plagiocephaly, part II: management

Non-synostotic deformational plagiocephaly (DP) is a common condition that affects as many as one in five infants in the first 2 months of life. The purpose of this article, the second in a two-part series, is to present a synthesis of the evidence related to management of deformational plagiocephaly and an evidence-based clinical decision tool for multidisciplinary management of DP. We systematically reviewed and graded the literature on management of DP from 2000 to 2011 based on level of evidence and quality. The evidence suggests that although many cases of DP will improve over time, conservative management strategies such as repositioning, physical therapy, and cranial molding devices can safely and effectively minimize the degree of skull asymmetry when implemented in the first year of life. Outcomes are best when the timing of diagnosis and severity of asymmetry guide decision making related to interventions and referrals for DP. Prevention and management of early signs of DP are best achieved in a primary care setting, with multidisciplinary management based on the needs of the child and the goals of the family.

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.

Evidence-based care of the child with deformational plagiocephaly, Part I: assessment and diagnosis

Non-synostotic deformational plagiocephaly (DP) is head asymmetry that results from external forces that mold the skull in the first year of life. Primary care providers are most likely to encounter DP when infants present for well-child care, and for this reason it is important that providers be competent in assessing, diagnosing, and participating in the prevention and management of DP. The purpose of this two-part series on DP is to present an overview of assessment, diagnosis, and evidence-based management of DP for health care providers. In Part I we provide a brief background of DP and associated problems with torticollis and infant development, and we present strategies for visual and anthropometric assessment of the infant with suspected DP. We also provide tools for differentiating DP from craniosynostosis and for classifying the type and severity of lateral and posterior DP. Part II (to be published in a future issue of the Journal of Pediatric Health Care) provides a synthesis of current evidence and a clinical decision tool for evidence-based management of DP.

In God's image? The tradition of infant head shaping

Intentional modification of the infant's head has been commonly practiced at all times and in virtually every region of the inhabited world. Motives included aesthetic perception of the human head, greater attractiveness, symbolization of ethnic identity, demonstration of noble origin or sociocultural status, and supposed health benefits. The desired shape was achieved by repeated hand massage, or by using devices like cradleboards, which were applied throughout infancy. In some regions, infant head shaping was the rule rather than the exception. Whereas chronic modification of the skull during the first year of life had no adverse effects, one-time postnatal head shaping by the midwife was a dangerous procedure. Recommended by Soran in the second century CE, it remained in practice for 17 centuries. With the advent of positional plagiocephaly following the back-to-sleep campaign, head shaping has regained acceptance and is now being widely used again.

Serial developmental assessments in infants with deformational plagiocephaly

AIM

An association between positional plagiocephaly and developmental problems has previously been noted, but whether delays persist over time has not been established. This study aimed to determine developmental outcomes for children with deformational plagiocephaly over 1 year of follow up.

METHODS

This was a longitudinal cohort study of 126 infants with deformational plagiocephaly recruited at an outpatient clinic. Development was assessed with the parent-completed Ages and Stages Questionnaires at recruitment and repeated at follow-up assessments in the home 3, 6 and 12 months later. Questionnaires were scored according to cut-off scores from the Ages and Stages Questionnaires, Third Edition.

RESULTS

Ninety-six percent of children were followed up for the full 12 months. The existence of one or more delays initially was 30%; this rose to 42% at the 3-month follow up then dropped back to 23% by the 12-month follow up. Delays were predominantly in the gross motor domain. Ten percent had > 4 delays in total over the four assessments. Mothers with tertiary education were more likely to have infants showing delays that persisted over time.

CONCLUSIONS

Infants with deformational plagiocephaly exhibited marked delays especially in early infancy. These delays were largely gross motor in type but had reduced to approach the expected level by the time of the 12-month follow up, at a mean age of 17 months.

Prevention of deformational plagiocephaly in neonates

BACKGROUND

Since the early 90s a striking rise in deformational plagiocephaly (DP) has been reported, and a causal link between the "back to sleep" position recommended to reduce the risk of sudden infant death syndrome. Recent data suggested that supine position is a risk factor only when combined with other environmental factors

OBJECTIVE

To evaluate the impact of early intervention in the newborn environment on the prevalence of DP at 4 months of life.

METHODS

A multicentric, prospective, controlled study in healthy term neonates. Within 72 h of birth, all parents received the usual recommendations for positioning their infants to prevent sudden infant death syndrome. In the Intervention group, recommendations were also given to encourage spontaneous and unhindered physical movement. At 1, 2 and 4 months, we looked for plagiocephaly and collected information on the infants' environment.

RESULTS

The environment of the Intervention group (n = 88) was significantly more favorable to unhindered movement than in the control group (n = 51) (lower immobility score, p < 0.01). The prevalence of DP was significantly lower in the Intervention group than in the control group (13% vs. 31%, p < 0.001). For each supplementary hour of immobility during the third and fourth months of life, the risk of DP at four months doubled (OR:2.1[1.4-3.2]).

CONCLUSION

Early postnatal intervention on the maternity ward reduces the prevalence of DP. The recent rise in the incidence of DP could be related to a lack of stimulation and encouragement to physical movement rather than to supine positioning proposed for prevention of sudden infant death syndrome.