Presentation is loading. Please wait.

Presentation is loading. Please wait.

Positional Plagiocephaly The Shape of Affairs

Similar presentations

Presentation on theme: "Positional Plagiocephaly The Shape of Affairs"— Presentation transcript:

1 Positional Plagiocephaly The Shape of Affairs
November 21, 2009 Patricia Mortenson Dr. P. Steinbok Alan Keith

2 Agenda (Approximate) 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

3 OBJECTIVES 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

4 PLAGIOCEPHALY? “oblique head” Causes
Deformational forces on moldable skull Nature of the infant skull Uterine & post-natal positioning Gravitational forces Correlation with torticollis Oblique head More cases since 1992 American Academy of Pediatrics “back to sleep” campaign – but also significant decrease in the incidence of SIDs Causes Infant skull is not fused together at birth – happens after about 12 months of age, therefore the skull is “moldable” In pregnancy a baby may be confined or squished and may develop a flat spot or tight neck Forceps or vacuum suctions at birth may create a flat spot Post birth, newborn can’t actively turn head therefore the head will fall to any flat area any pre-existing flat spots may be exaggerated or a new flat spot may form with positioning – especially if the baby spends a lot of time on his back or in car seats/ swings etc. Another cause is torticollis (tight neck) – with this the baby is only able to look to one side and this may create a flattening

5 INCIDENCE More cases with Back to Sleep At birth 13% in singletons
(Persing et al., 2003) At birth 13% in singletons Flat spots in 56% of twins (Peitsch et al., 2002) 61% asymmetry of the head; 16% torticollis (Stelleagen et al., 2008)

6 Natural History 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)

7 RISK FACTORS Caregiving Factors Bottle feeding Boy
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) Boy First born Multiple birth Prematurity Intrauterine constraint Torticollis Developmental delay Macrocephaly

8 Plagiocephaly & Torticollis
Variable reported co-relations: e.g. 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

9 Types

10 Occipital Positional Plagiocephaly
Unilateral occipital flattening Ear may be forward (Ipsilateral) Forehead and cheek may be forward (Ipsilateral)

11 Brachycephaly Bilateral occipital flattening Side of head widened
Bilateral occipital flattening Side of head widened

12 Positional Scaphocephaly
Long and narrow head More common in premature babies


14 HISTORY Pregnancy, Birth & Neonatal history
When did parents first notice Stayed same, gotten better/worse? Torticollis? What strategies have they already tried

15 HISTORY Positioning for sleep, feeding, play ? Tummy Time
Time spent in car seats, swings etc. Development

16 CLINICAL ASSESSMENT View from top, back, sides, front

17 CLINICAL ASSESSMENT Describe shape of head


19 CLINICAL ASSESSMENT Eye symmetry & shape
When in doubt refer to neurosurgery

20 Clinical Assessment Check head turning and tilt
If possible, assess in sitting, supine & prone

21 ? How to Quantify

22 Measurement Challenges: Variety of methods: 2D measures on 3D object
Squirmy subjects Variety of methods: Visual ratings Anthropometric (caliper measures) Digital photos CT scan Laser scanner

23 Measurement Issues Issues with Need standardized classification system
Reliability Cost Radiation & Sedation (Mortenson & Steinbok, 2006) Need standardized classification system (McGarry et al., 2008)

24 For now…. Argenta’s clinical classification
Severity assessment sheets available at: ? Reliability / validity

25 Argenta’s Classification
Type I just back of skull Type II adds mal position of I/L ear Type III adds forehead deformity Type IV adds facial deformity Type V adds temporal bossing or C/L bossing Argenta, 2004

26 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


28 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)

29 Argenta’s Classification
Type I central posterior skull Type II widening of the skull Type III Temporal or vertical skull growth Argenta, 2004 ? Reliability/validity




33 TREATMENT - Positioning
Rapid head growth Positioning for prevention and treatment Reverse process Re-positioning works as both prevention and treatment It works by trying to reverse the process An infants head grows very quickly in the first year, the skull will grow out as long as nothing is pushing back

34 SLEEP POSITION Place in crib so baby looks into room on the “round” side Place mobile/crib mirror on “round” side Turn head when asleep

35 SLEEP PRODUCTS 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.” in sleep – Old way - try to position baby in slight side sleeping – use tight blanket rolls or wedges – no pillow, loose blankets – now can’t due to paediatric academy statements Position baby in the crib so that she is looking out into her room onto the non-flat side Move mobiles, crib mirrors etc to the other side Once a baby can roll around at will in his crib, re-positioning in sleep will be hard, but he will also be moving off his back more

36 POTENTIAL PRODUCTS Not approved by CPA Cautious use, Safe T Sleep
Not approved by CPA Cautious use, Hutchison et al., 2007

Custom molded “dish” for head to rest in during sleep Weak evidence that effective in correcting early plagio (Rogers et al., 2008) ? Safety and approval for use

38 UPRIGHT Use of carriers Hip belts & wide straps Ergo carrier
Baby Trecker

39 PLAY POSITION Awake & up Tummy time Supported sitting
Side lying for play Tummy time – supervised time on tummy – use frequent short times to build up tolerance, caregivers to get down on floor with baby and use toys, mirrors to make more interesting (DEMO) Time on chest

40 TUMMY TIME Start with short but FREQUENT times Options include:
On chest Over legs Supported on Floor

41 TUMMY TIME TEACHING BE: Encouraging Realistic
Demonstrate on baby OR doll

42 BUMBO Not all babies tolerate never use on an elevated surface

43 SIDE LYING On Round side Best for pre-rollers Rolled blankets
“Sleep” positioning devices

44 FEEDING POSITION Bottle feed from “round” side
Feed from “round” side in highchair

45 BABY EQUIPMENT Car seat stays in car Stroller 101 Limit Swing Use
Good equipment Awake and up – decrease time spent in car seats, swings etc. Use slings, carriers, if old enough supported sitting, exersaucer etc. Recommend BUMBO seats, exersaucer,

46 IMPORTANT FACTORS Multiple options for caregivers Realistic
Demonstration as needed Address any developmental factors

47 TREATMENT - Orthotic Headband
Indications Moderate/severe Face involved Positioning not working How it works Wear 23 hours/day for months Limitations Cost Commitment Hot weather

48 TREATMENT – Other issues
Torticollis – need to treat Positioning not as effective (Losee et al., 2007) Motor & Developmental delays Parental guilt


50 OUTCOMES Natural improvement
(Hutchison et al., 2004) Conflicting evidence – 3 systematic reviews 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)

51 Controversies Limitations in studies:
No standard measures, poor reliability & validity No Randomization Observer and intervention biases Observers not blinded More severe cases selected to head band groups

52 Intensive Intervention
RCT van Vlimmeren, et al., 2008 380 neonates at 7 wks → 68 had positional preference 65 Randomized to 2 groups: Control → pamphlet only Intervention → 8 PT sessions for positioning & development Intervention group → severe plagio reduced by 46% (6 mos) & 57% (12 mos) At 12 months: No differences in motor development No positional preferences either group

53 Head banding – long term f/u
Changes post head band are stable at 5 years post treatment (Lee et al., 2008)

54 What to do in cases of poor evidence?
What is the goal? Potential benefits Potential harm Uncertainty about estimates of these Regret with a wrong decision Improved quality of life Improved cosmetics Cost and time High degree of uncertainty ? Likely low Phelps, 2008

55 OUTCOMES Age of identification & treatment is important
Early identification & treatment = better results (Losee et al., 2007; Persing et al., 2003; McGarry et al., 2008)) > 12 months – little improvement

56 EMERGING CONSENSUS? Infants < 5-6 months → positioning
Infants > 6 months → headband (if no improvement and facial involvement) Infants > 12 months →limited efficacy (Losee & Mason, 2005; Graham et al., 2005; McGarry et al., 2008; Xia et al., 2008)

57 SEQUELAE Not well studied Weak evidence Many claims unsubstantiated:
Migraines Vision problems

58 Sequelae Bonding Hearing & Vision Dental
Infants with molding less cute (Budrea, 1989) Hearing & Vision No strabismus (Gupta et al., 2003) ↓Auditory responses (Balan et al., 2002) Dental At 5 yrs, ? Occlusal deformities that may impact orthodontic planning – not formally studied (Lee et al., 2008)

59 SEQUELAE - Development
Different distribution of Bayley II scores than norms (Kordestani et al., 2006; Panchal et al., 2001) Mental → 90% normal; 0 accelerated; 7% mild delay; 3% severe delay Motor → % normal; 0 accelerated; 19% mild delay; 7% severe delay Other confounding variables Overstate delay - ? Significant mental delay (yet % delays within standardized norms)

60 SEQUELAE - Development
↑Special needs at school (39.7%) (Habal et al., 2003) More likely to have altered tone compared to control group No sig. difference in development (Ages & Stages) (Fowler et al., 2008) Anthropological evidence - head deformation does not lead to cognitive impairment (Lekovic et al., 2007)

61 Development Factors 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

62 PRONE DEVELOPMENT Systematic review by Pin et al., 2007:
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

63 LONG TERM SEQUELAE Not well studied At 5+ years:
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)

64 LONG TERM SEQUELAE 18 had used headbands – 14 felt had helped “quite a bit” 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

65 LONG TERM SEQUELAE 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 Overall reassurance for parents

66 LONG TERM Govaert et al., 2008 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

67 PARENTAL CONCERN Awareness vs. Information overload fueling consumer drive TV, newspaper and magazine stories Parent support networks, chat groups Commercial products


69 BCCH PROGRAM 4 years ago reaching “critical level” of referrals to neurosurgery Impact on wait times for critical neurosurgical consults & infants with PP Limited resources

70 BCCH PROGRAM OT Plagiocephaly Clinic
Parent education group with individual assessment Concurrent with Torticollis & Neurosurgery clinics 4 new patients/wk, 2 follow-ups

71 BCCH PROGRAM Parent Satisfaction & waitlists tracked over first year of program: Parents reported: 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.

72 BCCH PROGRAM Small program (0.1 FTE) Impact of over referrals
No need to refer mild cases

73 Other Health Regions Families outside lower mainland not well served
Often sent down inappropriately or too late Opportunities for collaboration & regional clinics

74 WITHIN BC - Headbands Valley Orthocare Scanner?
No MSP coverage for headbands Pharmacare Ministry Extended Health Plans

75 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

76 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)

77 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)

78 TAKE HOME MESSAGES 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

79 RESOURCES Clinician’s Guide available Coming - Caregivers’ Guide
Reference list Websites with caution – search plagiocephaly

80 Comments? Questions?

Download ppt "Positional Plagiocephaly The Shape of Affairs"

Similar presentations

Ads by Google