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

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Presentation on theme: "Positional Plagiocephaly The Shape of Affairs November 21, 2009 Patricia Mortenson Dr. P. Steinbok Alan Keith."— 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 1. Define positional plagiocephaly & risk factors 2. Be aware of differential diagnoses 3. Learn assessment techniques 4. Understand treatment guidelines 5. Describe outcomes & sequelae 6. 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

5 INCIDENCE More cases with Back to Sleep (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 Boy First born Multiple birth Prematurity Intrauterine constraint Torticollis Developmental delay Macrocephaly Caregiving Factors 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)

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


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

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 Eye symmetry & shape When in doubt refer to neurosurgery

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


22 Measurement Challenges: – 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 – Classification – Reliability – Cost – Radiation & Sedation (Mortenson & Steinbok, 2006) Need standardized classification system (McGarry et al., 2008)

24 For now…. Argentas clinical classification Severity assessment sheets available at: – ? Reliability / validity

25 Argentas Classification Type I just back of skull Type IIadds mal position of I/L ear Type IIIadds forehead deformity Type IVadds facial deformity Type Vadds temporal bossing or C/L bossing Argenta, 2004

26 Argentas 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 Argentas Classification Type Icentral posterior skull Type IIwidening of the skull Type IIITemporal or vertical skull growth Argenta, 2004 ? Reliability/validity




33 TREATMENT - Positioning Rapid head growth Positioning for prevention and treatment Reverse process

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.

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

37 POTENTIAL PRODUCTS Cranial cup 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

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 supervise

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

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: 1. No standard measures, poor reliability & validity 2. No Randomization 3. Observer and intervention biases – Observers not blinded – More severe cases selected to head band groups

52 Intensive Intervention RCT van Vlimmeren, et al., 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 – 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 74% 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 dont 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 Clinicians Guide available Coming - Caregivers Guide Reference list Websites with caution – search plagiocephaly

80 Comments? Questions?

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