Conservative Management of Infants with Positional Plagiocephaly: the
best evidence for physiotherapy practice
Prepared for Queen Alexandra Centre for Children’s Health
2400 Arbutus Road
Victoria, BC V8N 1V7
January 31 2007
Prepared by: Lynn Purves and Joan Glover
Preface
The Queen Alexandra Centre’s Evidence Based Practice Group (EBPG) was
established as part of a one year pilot project to develop a framework for
answering clinically relevant questions for Speech and Language Pathologists,
Occupational Therapists and Physiotherapists based on the best available
research, and to apply this framework to an initial set of the most pressing
clinical issues facing these stakeholders.
The goal is to develop a model for the collection and analysis of relevant
scientific literature, including evidence-based medicine reviews, clinical
guidelines, and research articles, to determine the best available treatment
options.
Queen Alexandra Centre’s Evidence Based Practice Group includes:
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Susan Gmitroski, Senior Occupational Therapist
Phil Harmuth, Senior Speech and Language Pathologist and
Coordinator of the Swallowing Disorders Clinic
Lynn Purves, Senior Physiotherapist and Coordinator of the
Neuromuscular Clinic
Joan Glover, Resource Physiotherapist, Early Intervention
Program
Victoria Korby-Fuchs, Resource Occupational Therapist,
Early Intervention Program
Thanks go to:
Corinne Dulberg, PhD MPH, Research Consultant, VIHA
Cliff Cornish, VIHA Library
Overview:
Plagiocephaly means “skewed head.” It is a result of mechanical factors,
which, over time, either in utero, at birth or postnatally, alter the skull
shape. Most often positional plagiocephaly is perpetuated by postnatal
positioning of the infant on the same part of his head every night so that a
flattened spot develops. This flat spot tends to worsen as the head tends to
more easily come to rest on the flattened spot.
Typically an infant with
plagiocephaly will develop a
parallelogram shaped skull with
ipsilateral occipital flattening and
frontal bossing. The ipsilateral ear
is anteriorly placed. There is
contralateral occipital bossing.
There may be cheek, mandible and
eye asymmetry. Diagram and
description from Losee (1).
The “Back to Sleep” campaign was
initiated in 1992 in the U.S. and
1993 in Canada as epidemiological
studies had found that infants who
slept on their stomachs had an 11.7
times higher risk for sudden infant
death syndrome (SIDS). In the
U.S. the prevalence of prone infant sleeping decreased from 70% in 1992 to
10.5% in 1997. The incidence Of SIDS was reduced from 2.6/1000 in 1986
to 1/1000 in 1998. The incidence of plagiocephaly has increased from 1/300
to 1/60 between 1974 and 1996(2)
Plagiocephaly has been a fairly new reason for referral to physiotherapy at
QACCH, only occurring over the past 3 to 4 years, but with a gradually
increasing rate of referral to physiotherapy. Physiotherapists in the Early
Intervention Programme have been seeking information regarding best
conservative management of these clients, as it is a new condition to most of
us.
Objectives:
To review the evidence for the best practice in the conservative
management of infants with plagiocephaly.
 To develop guidelines for physiotherapy management of infants with
plagiocephaly who are seen through the Early Intervention Program at
Queen Alexandra Centre
 Ensure knowledge transfer to clinicians at QACCH working with
infants with plagiocephaly
Methods

Databases were searched for searched for references related to
plagiocephaly OR positional plagiocephaly OR nonsynostotic plagiocephaly
AND treatment OR physiotherapy OR helmet therapy OR management. The
Cochrane Database of Systematic Reviews, The Cochrane Register of
Controlled Trials and the Database of Reviews of Effectiveness were
searched first to find any systematic reviews of the literature related to
plagiocephaly. Pub Med, Medline, PEDro (Physiotherapy Evidence Database)
and the ACP Journal Club were subsequently searched for the same topics.
The last Literature search was conducted on Nov 8 2006.Two
physiotherapists reviewed the resulting abstracts of articles obtained and
separately chose those that might be pertinent to our quest. If there was
disagreement, we requested and reviewed the article.
CONSERVATIVE MANAGEMENT-The best evidence:
Bialocerkowski et al (3) conducted a systematic review of all research
reports related to conservative treatment of plagiocephaly published
between January 1983 and Dec 2003. This systematic review was assessed
by 3 independent raters from the QACCH Evidence Based Practice group;
two physiotherapists and one research consultant, using the “University of
Glasgow; Critical Appraisal Checklist for a Systematic Review” (4) This
review scored 10/10 in fulfilling the criteria of a good systematic review
Bialocerkowski et al conducted a rigorous search of all research papers
related to plagiocephaly and included those which used a quantitative design,
investigated conservative management of positional plagiocephaly, and have
reported results for children less than one year of age. They included 16
studies in their review. None of these studies were randomized controlled
trials (level I level of evidence) but were rather case series or comparison
groups, not randomly assigned (level III or IV). They report “considerable
biases were present within each study”.
They also assessed the quality of each study using the criterion developed
by Law et al (5) and found poor to moderate quality with an average score of
7/16. Please see tables at end of report for the author’s table presenting
the studies included
The conservative treatments investigated included counter-positioning, with
or without physiotherapy, physiotherapy, and helmet therapy.
Counter-positioning involves the active repositioning of the child during sleep
and play to apply pressure to the prominent areas of the skull and reduce
the forces on the flattened area. Physiotherapy involved stretching of the
tight cervical musculature and promotion of positions to reduce forces on
the flattened area of the skull. Duration, frequency and specific techniques
used were not described. Helmet therapy included dynamic orthotics and
headbands, which apply pressure to abnormal skull prominence and relief
where skull growth is required. They note that the findings of these studies
must be interpreted with caution due to the designs and qualities of the
studies.
Graham and Lucas suggest that counter positioning can be effective in
infants with mild plagiocephaly. Helmet therapy may be effective in reducing
plagiocephaly, particularly in infants with moderate to severe plagiocephaly.
There is some discrepancy in the results of studies that compared counter
positioning +/- physiotherapy with helmetting. Mulliken and Vles concluded
helmets are more effective because they correct more rapidly. Moss and
Jalaluddin concluded that counter positioning is as effective as helmets.
The major weakness of these studies has been the lack of control groups or
randomization into groups.
There may have been some discrepancies between studies:
-Age at which treatment started
-How plagiocephaly was assessed /diagnosed
-Severity
-Incomplete data on children lost to follow up
-Accuracy and reliability of outcome measures
Some of the conclusions the authors of this systematic present include:
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Counter positioning +- physiotherapy or helmet therapy may have
beneficial results at reducing positional plagiocephaly
There is a need for a standard outcome measure with evidence of
reliability and validity so that there can be confidence that the
magnitude of change is greater than the margin of error.
As plagiocephaly is a cosmetic problem, the outcome measure should
reflect the parent’s perception of cosmetic appearance.
Two qualitative clinical trials re the conservative management of
plagiocephaly subsequent to Bialocerkowski’s systematic review were found
in our literature search. Two physiotherapists evaluated these later clinical
trials not been, using the same Critical Review Form-Quantitative Studies
(5) that was used in their review as well as grading the Levels of Evidence
(6).
Graham et al (2) published a study in 2005 that was not included in the
Bialocerkowski review. They evaluated 298 babies referred for head
asymmetry. 176 infants were treated with repositioning, 159 with helmets
and 37 with initial repositioning followed by helmet therapy. They report
that all infants with plagiocephaly had some associated torticollis and were
treated with physiotherapy, not specifically described, and followed at
monthly intervals. Helmet therapy was used for infants 6 months or older
with cranial diagonal difference of more that 1 cm as this was their previous
standard of care. There was not random allocation to treatment groups in
these cases. They state “most authors agree that if there is little
improvement in head shape in young infants being treated with repositioning
and physiotherapy, orthotic therapy should be initiated while there is still
enough residual head growth to allow for correction.”
This study was evaluated by two physiotherapists in the evidence based
practice group, using the critical review form for quantitative studies,
developed by Law (5) and scored 9/16 indicating only moderate quality of the
report, so conclusions must be interpreted with caution. This study was level
III in levels of evidence.
Graham et al concluded that both repositioning and helmet therapy work
when used appropriately with neck physiotherapy. They found that infants
treated with orthotics had a final skull shape closer to normal and that
orthotic therapy was more effective in reducing skull asymmetry (61%
reduction) compared to repositioning (52% reduction) and that early
orthotics (before 8 months) were more effective that later orthotics (after
8 months)
They did note some of the limitations of their study including the lack of
random assignment to study groups and the inability to quantify how small,
statistically significant differences in outcome might relate to parent
perception of cosmetic significance.
In many of the clinical trials included in the review by Bialocerkowski and in
the trial by Graham, the infants with moderate to severe plagiocephaly were
not randomly assigned to helmetting or repositioning groups because of the
current standard practice at that centre that older, more severe babies
should have helmet therapy. In several studies some infants were initially
treated with counter positioning but moved into an orthotics study group if
improvement was not sufficient. In these cases this is the result of clinical
experience at that tertiary centres treating plagiocephaly (2, 7,)
Graham et al recommend that if there is more than 1 cm. difference in
diagonal distances, measured by calipers, at 6 months of age, orthotic
therapy can be effective. (7)
Also subsequent to the systematic review by Bialocerkowski: Bruner et al (8)
followed 69 children with plagiocephaly who underwent soft shell helmet
therapy. Skull asymmetry was measured using computer tomography, before
therapy and 6 months after therapy began. Generally the infants wore the
helmets full time for 12 weeks then at night only. The average duration of
treatment was 7 months. Only 34 infants completed the study. 88% of these
subjects were compliant with helmet therapy and in the compliant patients, a
36% to 39% reduction in cranial asymmetry was found. He concludes that
helmet therapy is effective and cost effective at reducing cranial
asymmetry. Although Bruner et al used a more advanced measurement,
computer tomography, which is less likely to have error or bias that the
manual measurements used in other studies, almost half of the subjects
were lost to follow up with no reasons given and results were not reported on
the 4 subjects who completed the trial but were judged to have poor
compliance with helmet therapy.
This study was evaluated by two physiotherapists in the evidence based
practice group, using the critical review form for quantitative studies,
developed by Law (5) and scored 8/16 indicating only poor to moderate
quality of study design and level IV level of evidence, so results must be
interpreted with caution.
Loveday (7) reported that infants who fail to show improvement with
conservative management are potential candidates for cranial molding
orthotics. The orthotics take advantage of the fact that 85% of skull
growth occurs during the first year of life. He concluded, “ A combination of
the two management regimens could be the most effective management of
plagiocephaly.”
The American Academy of Pediatrics, clinical guidelines on the prevention
and management of positional skull deformities in infants (9) cites the
conflicting results from different studies comparing repositioning and neck
exercises and helmet therapy and concludes that the use of helmets seems
to be beneficial primarily when there has been a lack of response to
mechanical adjustments and exercise.
Clinical Notes re counter positioning
Graham et al (2) emphasized the need to position infants 3/4 turned to the
side, with the head resting on the occipital prominence and that it is
important that parents be warned not to simply position the child on the side
of their head, as it does not correct cranial asymmetry and the child is in
danger of rolling to prone. They recommend the use of positioning devices
that allow a baby to be positioned in the ¾ turn. We are limited in our
practice as this is contrary to the recommendations of the Canadian
Paediatric Society who recommend that products to maintain the sleep
position not be used and that soft bedding such as pillows, comforters,
bumper pads and lambskin or similar products is kept out of the sleep
environment. Most authors emphasize the need to position the infant so
that mattress pressures shift to the non-flattened aspect of the occipital
skull, not side lying.
Several authors mention that counter positioning may be less effective
after about 6 months of age because a typical infant is actively moving
enough that it is difficult to maintain pressure on the non-flattened occiput.
In Loveday and de Chalain’s study (7) caregivers are told to never allow the
infant to sleep on the flat spot on his head. Rooms are to be rearranged so
that “interest” is not on the flat side (attention to doors, window, mobiles,
coloured objects.) The position of the car seat in the car may require
modification. Nursing and carrying positions may also be adjusted. Active
head turning activities were incorporated into play. Loveday and Chalain were
very specific about all of these instructions to caregivers and were also
among the studies included in Bialocerkowski’s review that found counter
positioning had a slightly better outcome than helmet therapy although the
management period was approximately 3 times longer.
Graham et al (2) also strongly recommended early, supervised tummy-time to
promote neck range of motion and prone skill development as well as
correcting positional preference.
Clinical notes re helmetting:
Loveday (7) reported several concerns that arose during helmetting:
-Proper fit was difficult and they often had to be modified many
times
-Helmets became hot and sweaty and caused some heat rashes
-At times there was skin injury over pressure points
-Older infants could undo the chinstrap and remove helmet
-Brachycephalic children were more difficult to helmet as the helmet
tended to slip
-Some infants did not accept the helmet and became distressed. This
was more common in older infants
-Some caregivers were embarrassed by the helmet.
Many authors mention the cost of helmets being a significant factor in
the decision to provide helmetting, particularly when the study outcomes do
not clearly favour helmets over counter positioning and exercise (9)
Graham compared the results of infants who started helmet therapy
before 8 months with those who began when more than 8 months and found
that the final asymmetry was greater and the percentage of change was less
in the older group (52%vs. 65%)
Teichgraeber also noted that in infants with brachycephaly, helmet
therapy was less effective because of the difficulty fitting it so that it
doesn’t shift. Usually the occiput is a strategic prominence for anchoring the
orthotic. (10)
Teichgraeber also found no statistically significant difference in the
results of helmetting based on age of infants who all began helmet therapy
before one year of age. (10)
ASSOCIATED TORTICOLLIS
Losee (1) reported associated contralateral torticollis in 3 to 20% of
children with plagiocephaly.
Loveday (7) reported that torticollis is associated with 64 to 84% of infants
who develop positional plagiocephaly. He too notes that congenital SCM
tightness may be a factor in the development of torticollis, but may also be
secondary to persistent positional preference.
Persing (9) notes that torticollis coexisting with plagiocephaly may be the
consequence of hemorrhage and subsequent scarring within the stern-cleidomastoid muscle (SCM) or that it may be muscle shortening caused by
persistent unidirectional positioning and limited neck motion.
Graham (2) reported that all infants with positional plagiocephaly had some
degree of associated torticollis. All of the infants in their study received
physiotherapy, whether they were in the counter positioning or helmet
therapy group.
Van Vlimmeren (11) differentiates between congenital muscular torticollis
with unilateral contracture of SCM and positional torticollis due to
persistent positional preference. He also reviews specific physiotherapy
procedures for treating torticollis and their effectiveness. These are not
reported here as this was not a full systematic review of torticollis
physiotherapy treatment and was felt to be beyond the scope of this to take
that review further. This has potential for another topic to be reviewed by
the EBPG.
Golden et al (12) studied 100 infants referred for treatment of
plagiocephaly to investigate the existence of SCM imbalance and torticollis
in this population. They describe a congenital muscular torticollis as a fixed
or restricted SCM on one side with a reduction of active and passive range
of motion. Classically the infant’s neck is side flexed to one side and rotated
contralaterally. This was found in 12% of their study group. They define a
sternocleidomastoid imbalance as a decreased ability to actively rotate or
laterally flex the neck to one side but with normal passive range of motion.
SCM ay be taut but examiner can usually attain full range of motion within 3
tries. The baby may have an intermittent head tilt and or favour rotation to
one side. In their study group 64% of infants presenting with plagiocephaly
demonstrated SCM imbalance. They hypothesize that with early detection of
sternocleidomastoid involvement it could be therapeutically addressed,
potentially preventing or lessening craniofacial deformity.
De Chalain and Park (13) also describe a high incidence of torticollis
associated with plagiocephaly, which, though apparently benign (mild head
tilt and only a few degrees limitation of range of motion), is important to
seek and treat. It may lead to persistence or exacerbation of the
plagiocephaly. If untreated a true neck contraction may develop. “Together
(and the effects may be more than additive) torticollis and plagiocephaly
predispose to and cause deformations of the skull base and hence of the
entire craniofacies” Chalain stresses the need for active treatment of the
torticollis by physiotherapy concurrent with management of the
plagiocephaly.
References found during the literature search which contained information
relevant to physiotherapy practice at QACCH were also reviewed though
they were not specifically clinical trials of conservative treatment. This
includes information on:
Natural history of Plagiocephaly
Incidence and determinants of plagiocephaly
Simple assessment of plagiocephaly (methods within our scope of
practice/technologically available to us)
Associated problems such as visual and neurodevelopmental delays
This information has been included if the information included might
influence practice at Queen Alexandra Centre.
INCIDENCE
There are varying estimates of the new incidence of plagiocephaly. Persing
(9) notes a six-fold increase in the incidence since 1992, when back to sleep
was introduced in the U.S. Graham suggests an incidence of 1 in 60. A
prospective study in the Netherlands (14) of over 7000 newborns found the
incidence of positional preference to be 8.2%.
Of these children 45% demonstrated asymmetric flattening of the occiput,
21% of the forehead at the second assessment between age 2 and 3 (2.4%
of all children)
It has been suggested by Hutchinson (15) that the actual prevalence is
unknown but that as a result of increased awareness it is being recognized
more frequently
DETERMINANTS
Losee et al (1) reviewed some of the reported demographics from different
centres:
-Predominately male (60 to70%)
-Predominantly right sided (57 to70%)
-Increased incidence in white children (95% white, 2% African
American, 2% Hispanic. (He suggests this may be because “Back to Sleep”
was more readily embraced by the white population)
-Increased incidence is associated with multiparity (8 to 12.4%)
-Possibly incidence associated with prematurity (0 to 18.6%)
When Hutchinson et al (16) compared 100 infants with plagiocephaly with 94
matched controls they found they were more likely male, premature, not to
have head position varied, not to have spent more than 5 minutes a day in
prone and sleep in supine. They were more likely to be perceived by their
mother as less active, to have a developmental delay and to have developed a
preferred head orientation by 6 weeks of age.
Booreman et al (14) found a higher prevalence of positional preference in
first-born children, males, and infants born after breech delivery or
prematurely. They also found increased incidence in infants who were always
bottle fed with either the left or right hand.
PREVENTION:
Most authors stress the importance of prevention in reducing this “new
epidemic” of plagiocephaly (1,11,14,15,16,17,27,28) All agree that
preventative counseling to parents of newborns should include the
importance of alternating head position and encouraging tummy time for play
for more than 5 minutes a day when the infant is awake and observed
Many include changing orientation to outside activity (e.g. Changing which
end of the crib the infants head is at) and minimizing time in car seats
(unless in a vehicle) or other seats such as bouncy seats and encouraging
upright cuddle time (9,17,14)
It should be noted that some early work on plagiocephaly, at times,
recommended side lying to sleep however as of 2003 the American Academy
of Pediatrics no longer recognized side lying as a safe sleep position.
Hutchinson (16) reports that supine sleeping in the young infant is 6 times
safer than prone sleeping and twice as safe as side sleeping concerning SIDS
incidence.
NATURAL HISTORY:
Loveday reported that many health professionals tell parents of infants with
plagiocephaly that it will dissipate with time and though this may happen
occasionally, for the majority of children there will be some permanent
residual deformation. This may be mild or camouflaged by hair. (7)
Graham reported that the deformity persisted in almost 1/3 of cases when
reexamined at age 2 to 3.(2)
Losee et al report that in their clinical experience, significant asymmetry at
6 months of age does not self correct without treatment. (1)
Boere-Boonekamp et al (14), in a prospective study of over 7000 newborns,
found positional preference in 8.2% of infants. Of those 2.4% still had some
flattening of the skull or restricted range of motion between ages 2 to 3
Hutchinson al (15) followed 200 normal infants recruited at birth and found
the highest prevalence of positional plagiocephaly at 4 months of age (19%).
Overall, 29.5% of infants demonstrated plagiocephaly or brachiocephaly at
some stage during the follow up, mostly occurring at 6 weeks and 4 months
follow ups. Most cases improved with time so that prevalence was 3% at 2
years of age.
ASSESSMENT: The American Academy of Pediatricians recommends that
the assessment of plagiocephaly requires inspection from several angles. (9)
It is necessary to look down at the top of the head and note:
Position of ears
Position of cheeks
Occipital flattening/bossing
Frontal/parietal bossing
From face on one should note:
Head tilt
Contralateral facial flattening
Then observe active range of motion of the neck.
Most authors include the above inspection criteria in the assessment of
plagiocephaly. Hutchinson (15) specified the need to test passive neck
rotation in supine at newborn and 4 months of age, then from 6 months he
observed active neck rotation with the child visually following a toy while
seated on Mother’s lap.
Cranial Technologies offers an assessment form, which allows a framework
for the assessment of all but the neck movements, recommended above.
In prospective studies in the Netherlands (14) assessment for the presence
of muscular torticollis, scoliosis, limited hip abduction or anomalies of the
feet (club feet pes adductus) were included in their inspection.
Most authors talk about the importance of parent perception of cosmetic
severity of plagiocephaly as part of the assessment procedure and
assessment of effectiveness of treatment. (3,2,11)
It is beyond the scope of physiotherapy to diagnose synostosis; however,
physiotherapists treating infants with plagiocephaly should be alert to the
possibility of lamboidal synostosis. In lamboidal synostosis the pattern of
occipital flattening and ipsilateral frontal bossing is the same as in positional
plagiocephaly though frontal bossing is less. In lamboidal synostosis, however
the ear on the side of the flattened occiput is typically posterior and
inferior. The posterior basal skull may be tilted and the mastoid prominent.
Facial asymmetry tends to be minimal (9). Any concern re premature fusion
or abnormality of any of the sutures should be referred back to the child’s
physician.
Diagram of positional plagiocephaly differentiated from lamboidal
synostosis: from Losee
(1)
Quantitative assessment of plagiocephaly is an area of concern in the
literature, particularly in the clinical trials. (3) There is no standard tool
accepted. Some authors recommend computed tomography techniques but
these have been criticized because of cost, exposure to radiation, and risks
from anaesthetic (7)
Hutchinson et al (15) have developed a head shape measuring technique,
Heads Up, which involves an elastic head circumference band, with sliding
markers for ears and nose which is digitally photographed from above
Mortenson and Steinbok (18) conducted a study to investigate the reliability
and validity of anthropometric measurements using calipers. One examiner
was able to establish intra-rater reliability. The other was not. They were
not able to establish inter-rater reliability, nor were they able to correlate
their numerical measurements of cranial vault asymmetry with their visual
analysis of severity (mild, moderate and severe). These authors question
whether cranial vault asymmetry, though the best measure of cranial
asymmetry, is the most significant measurement in quantifying outcome that
is relevant. Plagiocephaly is predominantly a cosmetic concern, so there may
be assessments that are more meaningful cosmetically; for example face,
side and back views may be more important, perceptually, than top down.
Loveday (7) developed an assessment method, using an artist’s flexicurve to
obtain a circumferential head tracing, which they used to calculate a cranial
vault asymmetry index. They calculated their relative error as being  5%
ASSOCIATED PROBLEMS
Van Vlimmeren (11) reports that localized asymmetry, such as plagiocephaly
and torticollis, may be associated with more generalized asymmetry,
including head and face, scoliosis, rib cage molding, pelvic obliquity as well as
hip and foot asymmetry. Loveday reports that congenital hip dislocation,
scoliosis, SCM tumours and prominent ears may be associated with
plagiocephaly
Losee reported conflicting data regarding craniofacial changes affecting jaw
function, visual disturbances (strabismus and astigmatism), neurological
development and possibly auditory function.
Siatkowski et al (9) performed visual field testing on 40 children with
positional plagiocephaly. They found 35% of these children had constriction
of one or more visual fields. This is statistically different from previously
established normative data. They found that laterality of field defect was
not related to the side of flattening. There was a correlation between
severity of visual defect and severity of plagiocephaly but it was not
statistically significant.
ASSOCIATED DEVELOPMENTAL PROBLEMS
Several articles discussed the possibility of associated neurodevelopmental
problems with children with deformational plagiocephaly (DP). Miller et al
(20) report that males with plagiocephaly at birth are a high-risk group for
subtle developmental delay. Panchal et al, (21) in comparing Bayley scores at
8 months of a group of infants with DP with expected scores, that there was
a higher incidence of developmental delay. Kordestani et al, (22) in an
associated study to Panchal, reported that infants with DP who had
developmental delay also had confounding factors. None of the articles
reviewed showed strong evidence (low scores in critical review). Collet et al
(23), in a review article, which includes the above authors, summarizes the
issue with the statement that “these studies tentatively suggest that DP is
associated with increased risk for developmental delay: however a causal
association should not be presumed. Although there may be adverse effects
resulting from brain development in an asymmetric skull, it is also plausible
that DP is merely a marker for other conditions that impede development.”
He suggests further well-controlled research to study the effect of skull
deformation on brain development, the effect of brain development (or CNS
pathology) on skull shape, and the effect of positioning limitations on both
DP and motor development.
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TABLE 1 from systematic review bt Bialerkowski et al