Positional Plagiocephaly
The Shape of Affairs
November 21, 2009
Patricia Mortenson
Dr. P. Steinbok
Alan Keith
Agenda (Approximate)
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1:00- 1:15 Definition, incidence, risk factors
1:15- 1:45 Synostosis differential (Dr. Steinbok)
1:45 - 2:30 Assessment, treatment, outcomes,
sequelae
15 minute stretch break
2:45 - 3:15 Head banding (Alan Keith)
3:15 - 3:30 Clinical pathways, future, resources
3:30 - 4:00 Questions & problem solving
OBJECTIVES
1.
2.
3.
4.
5.
6.
Define positional plagiocephaly & risk
factors
Be aware of differential diagnoses
Learn assessment techniques
Understand treatment guidelines
Describe outcomes & sequelae
Know how and when to make appropriate
referrals in BC
PLAGIOCEPHALY?
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
“oblique head”
Causes
–
–
–
–
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Deformational forces on moldable skull
Nature of the infant skull
Uterine & post-natal positioning
Gravitational forces
Correlation with torticollis
INCIDENCE
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More cases with Back to Sleep
(Persing et al., 2003)
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At birth
–
–
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13% in singletons
Flat spots in 56% of twins
(Peitsch et al., 2002)
61% asymmetry of the head; 16%
torticollis
(Stelleagen et al., 2008)
Natural History
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
Followed 200 infants recruited at birth
Looked at plagiocephaly/brachycephaly:
–
–
–
–
16% at 6 weeks
19.7% at 4 months
6.8% at 12 months
3.3% at 24 months
(Hutchison et al, 2004)
RISK FACTORS
Caregiving Factors
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Boy
First born
Multiple birth
Prematurity
Intrauterine constraint
Torticollis
Developmental delay
Macrocephaly
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Bottle feeding
Tummy time < 3X/day
Tummy time < 5 min/day
Positioning in crib
(van Vlimmeren et al., 2007;
Hutchinson et al., 2003; Losee
et al., 2007)
Plagiocephaly & Torticollis
Variable reported co-relations:
e.g.

–
–
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From 5 – 67% in Texas wide review of
facilities/cases
Variation in diagnosis of CMT and SCM
imbalance
Depends on specialty of facility/service
Pivar & Scheuerle, 2006
TYPES
Occipital Positional Plagiocephaly
www.plagiocephaly.org
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Unilateral occipital flattening
Ear may be forward (Ipsilateral)
Forehead and cheek may be forward (Ipsilateral)
Brachycephaly
www.plagiocephaly.org
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Bilateral occipital flattening
Side of head widened
Positional Scaphocephaly
www.plagiocephaly.org
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Long and narrow head
More common in premature babies
ASSESSMENT & TREATMENT
HISTORY
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Pregnancy, Birth & Neonatal history
When did parents first notice
Stayed same, gotten better/worse?
Torticollis?
What strategies have they already tried
HISTORY
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
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Positioning for sleep, feeding, play
? Tummy Time
Time spent in car seats, swings etc.
Development
CLINICAL ASSESSMENT

View from top, back, sides, front
CLINICAL ASSESSMENT

Describe shape of head
CLINICAL ASSESSMENT
CLINICAL ASSESSMENT
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Eye symmetry & shape
When in doubt refer to neurosurgery
Clinical Assessment
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Check head turning and tilt
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If possible, assess in sitting, supine & prone
? HOW TO QUANTIFY
Measurement
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Challenges:
–
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2D measures on 3D
object
Squirmy subjects
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Variety of methods:
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–
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Visual ratings
Anthropometric
(caliper measures)
Digital photos
CT scan
Laser scanner
Measurement Issues
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Issues with
–
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Classification
Reliability
Cost
Radiation & Sedation
(Mortenson & Steinbok, 2006)

Need standardized classification system
(McGarry et al., 2008)
For now….
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Argenta’s clinical classification
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Severity assessment sheets available at:
www.cranialtech.com
–
? Reliability / validity
Argenta’s Classification
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Type I
Type II
Type III
Type IV
Type V
just back of skull
adds mal position of I/L ear
adds forehead deformity
adds facial deformity
adds temporal bossing or C/L
bossing
Argenta, 2004
Argenta’s Classification

Moderately reliable for Types I – IV
(flatenning, ear malposition, frontal
bossing, facial asymmetry)

but NOT for vertical skull height
(Spermon et al, 2008)

? Degree & responsiveness, ? Validity
Measurement - Brachycephaly

Cranial Index
Maximum head breadth X 100
Maximum head length
Scaphocephalic – up to 75.9
Brachycephalic – 81 and over

However ? New norms – wider head shapes
with supine sleeping
(Pomatto, et al., 2006)
Argenta’s Classification
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Type I central posterior skull
Type II widening of the skull
Type III Temporal or vertical skull growth
Argenta, 2004
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? Reliability/validity
TREATMENT
TREATMENT - Positioning
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Rapid head growth
Positioning for
prevention and
treatment
Reverse process
SLEEP POSITION
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Place in crib so baby looks into room on the
“round” side
Place mobile/crib mirror on “round” side
Turn head when asleep
SLEEP PRODUCTS
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American Academy Position Statement
“We recommend that firm flat bedding be used for normal
healthy infants, with sheets and light blankets as needed,
but without products to maintain the sleeping position.”
www.cps.ca/english/statements/IP/cps98-01.htm#sleep
POTENTIAL PRODUCTS
Safe T Sleep
 www.safetsleep.com
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Not approved by
CPA
Cautious use,
Hutchison et al., 2007
POTENTIAL PRODUCTS
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Cranial cup
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Custom molded “dish” for head to rest in
during sleep
Weak evidence that effective in correcting
early plagio
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(Rogers et al., 2008)
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? Safety and approval for use
UPRIGHT
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Use of carriers
Hip belts & wide
straps
Ergo carrier
Baby Trecker
PLAY POSITION
Awake & up
 Tummy time
 Supported sitting
 Side lying for play

TUMMY TIME
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Start with short but
FREQUENT times
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Options include:
– On chest
– Over legs
– Supported on Floor
TUMMY TIME TEACHING
BE:
 Encouraging
 Realistic
 Demonstrate on
baby OR doll
BUMBO
•Not
all babies tolerate
•never
use on an
elevated surface
•supervise
•www.bumbosafety.com
SIDE LYING
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On Round side
Best for pre-rollers
Rolled blankets
“Sleep” positioning devices
FEEDING POSITION
Bottle feed from
“round” side
 Feed from “round”
side in highchair
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BABY EQUIPMENT
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Car seat stays in car
Stroller 101
Limit Swing Use
Good equipment
IMPORTANT FACTORS
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Multiple options for caregivers
Realistic
Demonstration as needed
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Address any developmental factors
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TREATMENT - Orthotic Headband
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Indications
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How it works
Wear
–
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Moderate/severe
Face involved
Positioning not working
23 hours/day for months
Limitations
–
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Cost
Commitment
Hot weather
TREATMENT – Other issues
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Torticollis – need to treat
–
Positioning not as effective
(Losee et al., 2007)
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Motor & Developmental
delays
Parental guilt
OUTCOMES & SEQUELAE
OUTCOMES
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Natural improvement
(Hutchison et al., 2004)
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Conflicting evidence – 3 systematic reviews
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Positioning OR headband > than leaving be
Positioning = headband but takes longer
Helmet > positioning (most studies)
(Bialocerkowski et al., 2005; McGarry, 2008; Xia et al.,
2008)
Controversies
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1.
2.
3.
Limitations in studies:
No standard measures, poor reliability &
validity
No Randomization
Observer and intervention biases
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Observers not blinded
More severe cases selected to head band groups
Intensive Intervention
RCT van Vlimmeren, et al., 2008
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380 neonates at 7 wks → 68 had positional preference
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65 Randomized to 2 groups:
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Control
Intervention
→ pamphlet only
→ 8 PT sessions for positioning & development
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Intervention group → severe plagio reduced by 46% (6 mos)
& 57% (12 mos)
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At 12 months:
No differences in motor development
No positional preferences either group
Head banding – long term f/u
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Changes post head band are stable at 5
years post treatment
(Lee et al., 2008)
What to do in cases of poor
evidence?
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What is the goal?
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Potential benefits
Potential harm
Uncertainty about
estimates of these
Regret with a wrong
decision
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Improved quality of
life
Improved cosmetics
Cost and time
High degree of
uncertainty
? Likely low
Phelps, 2008
OUTCOMES

Age of identification & treatment is
important
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Early identification & treatment = better
results
(Losee et al., 2007; Persing et al., 2003;
McGarry et al., 2008))

> 12 months – little improvement
EMERGING CONSENSUS?
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Infants < 5-6 months → positioning
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Infants > 6 months → headband
(if no improvement and facial involvement)
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Infants > 12 months →limited efficacy
(Losee & Mason, 2005; Graham et al., 2005; McGarry et al., 2008;
Xia et al., 2008)
SEQUELAE
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Not well studied
Weak evidence
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Many claims unsubstantiated:

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Migraines
Vision problems
Sequelae
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Bonding
–
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Hearing & Vision
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Infants with molding less cute (Budrea, 1989)
No strabismus
↓Auditory responses
(Gupta et al., 2003)
(Balan et al., 2002)
Dental
–
At 5 yrs, ? Occlusal deformities that may impact orthodontic
planning – not formally studied
(Lee et al., 2008)
SEQUELAE - Development
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Different distribution of Bayley II scores than
norms
(Kordestani et al., 2006; Panchal et al., 2001)
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Mental → 90% normal; 0 accelerated; 7% mild
delay; 3% severe delay
Motor → 74% normal; 0 accelerated; 19% mild
delay; 7% severe delay
Other confounding variables
Overstate delay - ? Significant mental delay (yet %
delays within standardized norms)
SEQUELAE - Development
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↑Special needs at school (39.7%)
(Habal et al., 2003)
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More likely to have altered tone compared to
control group
–
No sig. difference in development (Ages & Stages)
(Fowler et al., 2008)
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Anthropological evidence - head deformation
does not lead to cognitive impairment
(Lekovic et al., 2007)
Development Factors
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Delay is a risk factor for PP
Children sleeping supine have slower motor
development
Most children with PP have Normal develop.
? PP a risk factor for delay VS children with
delays at ↑ risk of PP
Co relation NOT Cause/effect
PRONE DEVELOPMENT
Systematic review by Pin et al., 2007:
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Time in prone correlated to earlier motor milestones
BUT effect was transitory
Similar for pre-term infants, but only 2 studies
Baby equipment use does not seem to impact motor
? Movement quality differences
? Impact of lower SES &
infant position on development
LONG TERM SEQUELAE
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Not well studied
At 5+ years:
–
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Questionnaires completed by 65 families (278
eligible)
Residual asymmetry noted by parents in 58%;
21% concerned
2 felt to be “very abnormal”; 25 “mildly abnormal”
(Steinbok et al., 2007)
LONG TERM SEQUELAE
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18 had used headbands – 14 felt had helped
“quite a bit”
–
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Little difference in outcome, but initial bias for who
had been referred for bands
7.7% of children had commented about their
head shape
4.6% teased occasionally
LONG TERM SEQUELAE
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14% received special assistance in school
(BC average is 10.2%)
At initial diagnosis 8% had comorbid
diagnoses consistent with delay; 5% had risk
factors
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Overall reassurance for parents
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LONG TERM
Govaert et al., 2008
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QOL in post helmet group at preschool age by
questionnaire (47% response rate)
No differences in QOL compared to normal group
44/46 parents reported would do helmetting again
Weak study
PARENTAL CONCERN
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Awareness vs. Information overload fueling
consumer drive
TV, newspaper and magazine stories
Parent support networks, chat groups
–
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www.cappskids.org
Commercial products
WHAT WE ARE DOING IN BC
BCCH PROGRAM
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4 years ago reaching “critical level” of
referrals to neurosurgery
Impact on wait times for critical neurosurgical
consults & infants with PP
Limited resources
BCCH PROGRAM
OT Plagiocephaly Clinic
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Parent education group
with individual
assessment
Concurrent with
Torticollis &
Neurosurgery clinics
4 new patients/wk,
2 follow-ups
BCCH PROGRAM

Parent Satisfaction & waitlists tracked over first year
of program:
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Parents reported:
–
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feeling comfortable in the group setting
meeting other families was helpful
having all of their questions answered
positive experience
Wait times for infants with PP decreased from 4 to
<1 months.
BCCH PROGRAM
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Small program (0.1 FTE)
Impact of over referrals
–
No need to refer mild cases
Other Health Regions
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Families outside lower mainland not well
served
Often sent down inappropriately or too late
Opportunities for collaboration & regional
clinics
WITHIN BC - Headbands

Valley Orthocare
Scanner?
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No MSP coverage for headbands
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–
–
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Pharmacare
Ministry
Extended Health Plans
WHAT TO DO - Prevention


Back to sleep, tummy for play
Early parental awareness

Evaluation of head shape & care giving
routines at well baby visits

Early identification and treatment = better
results … but don’t stress parents
WHAT TO DO - Plagiocephaly

< 5 months – reposition and monitor

5 + months
If positioning not working
– Facial / ear involvement
– Moderate to severe
→ consider headband
→ can refer to BCCH OT dept
(need physician referral)
–
WHAT TO DO - Brachycephaly

More difficult to treat
–


Can try if severe, treat early
Look at family pattern
Flatter & wider may be the new norm
(Pomatto et al., 2006)
TAKE HOME MESSAGES
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
PREVENTION
Reassurance for mild cases
–
Monitor, but usually no need for further referral

Early Identification & treatment for moderate
to severe cases

Opportunity for collaboration for “Closer to
home” services
RESOURCES
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Clinician’s Guide available
Coming - Caregivers’ Guide
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Reference list

Websites with caution

www.cheo.on.ca
www.sickkids.ca – search plagiocephaly
www.plagiocephaly.org
www.cranialtech.com
www.cappskids.org
Comments? Questions?