1. Preventing Deformational Plagiocephaly Through Parent Guidance – a randomized, controlled trial
H. Aarnivala, V. Vuollo, V. Harila, T. Heikkinen, P. Pirttiniemi, A. M. Valkama
Dpt of Pediatrics and Dpt of Orthodontics,
Oulu University Hospital, Oulu, Finland
Eur J Pediatr (2015) 174:1197–1208
DOI /s x

2. Plagiocephaly Greek: plagio (oblique) – kephale (head)
May result from:
Unilateral synostosis (Synostotic Plagiocephaly)
Prevalence of unilateral lambdoid synostosis ≈ 0.003%
External forces (Deformational Plagiocephaly; DP)
Prevalence of DP % at 4 months, increasing over the past two decades
Craniosynostosis – rare -> Deformational (by external forces) is common
A common cause for concern in parents

3. Classic DP in a 3 month old girl – left occiput flattened, left ear shifted anteriorly, left side of the forehead is bulging

4. Deformational Plagiocephaly
Results from intrauterine or postnatal external forces
Intrauterine/birth-related deformation is transient, with little or no impact on the risk of later cranial asymmetry
Majority of cases develop during the first 2-4 months of life
Limited neck Range Of Motion (ROM) is often present
Mild cases generally resolve spontaneously; severe cases may require physiotherapy, even helmet therapy
Limited ROM can be either congenital muscular torticollis or associated positional torticollis

5. Deformational Plagiocephaly
Even with therapeutic intervention, craniofacial asymmetry may persist into later childhood
In theory, DP may increase the risk of subsequent occlusal defects
Associated mandibular & facial asymmetry
Mandibular and facial asymmetry, can be seen in later childhood
CT-scans have shown that rotation of the cranial base and displacement of the ipsilateral TMJ-joint may be present in children with DP
-> no direct evidence

6. Preventing Deformational Plagiocephaly
Several recommendations for prevention exist, but evidence of their effectiveness has been lacking
30 min of daily tummy time
Varying the infant head position, awake and asleep
One prospective case-control study (Cavalier et al ) has evaluated a preventive strategy
Promising results, some limitations
No RCTs so far…
Tummy time and varying the head position have been described as protective factors in retrospective studies
Some methodological limitations

7. Objective
To evaluate the effectiveness of an intervention in the newborn’s environment, positioning and handling on the prevalence of DP in a randomized, controlled trial

8. Methods & Materials
111 healthy newborns, randomized into two groups at birth
Before discharge, all families received standard positioning instructions to prevent SIDS
Intervention group also received instructions regarding the infant’s environment, positioning and handling
Focus on creating a non-restrictive environment promoting spontaneous movement and symmetrical motor development
Standard instructions: should be placed to sleep on their backs etc
Non-restrictive environment for the baby, …

9. Intervention group instructions included the following points:
When sleeping, baby’s head position should be alternated evenly between left/right.
The bed should have enough space for the baby to turn freely, and placed so that the baby receives stimuli (light, sound, etc.) equally from all directions.
When breastfeeding or bottle-feeding, sides should be alternated evenly.
Following 3 slides are basically a list of the instructions given – try to bear with me

10. Intervention group instructions included the following points:
Time spent in carriers, bouncers and car seats should be minimal.
When using them, head position should be alternated regularly.
Toys and other interesting objects should be spread out on the floor evenly. Parents should attract baby’s attention from both sides equally.
If light or other surroundings cause the baby to favor their direction, baby’s position should be alternated regularly in relation to them.

11. Intervention group instructions included the following points:
Tummy time should be started from birth, 30min / day.
If occipital flattening or positional preference is noticed, the opposite side should be favored when putting the baby to sleep, feeding, handling etc.
Stretching instructions were also provided, which were to be used in case the baby started showing neck muscle imbalance.

12. Methods & Materials Background data was collected from e-records
Subjects were first examined 24-72h after birth
Measurements of the neck ROM
Standardized 2D digital photograph of the cranium (vertex view)
Follow-up visit was held at 3 months
In addition to above, a 3D image of the head was captured using the 3dMDhead® 5-pod camera system
Stereophotogrammetry, ~1.5 ms exposure time
… in addition to the above procedures, a 3D …

13. Baby is seated on a chair and centered in the scanner, well – not that chair, but a high chair suitable for babies – and then the image captured with a total of 20 cameras in the 5 pods

15. Methods & Materials Using 5 craniofacial landmarks, the:
position of the 3D-image was standardized
measurement planes for outcome variables were defined
Cranial symmetry was quantified with several parameters:
Primary outcome variable = OCLR (Oblique Cranial Length Ratio)
Measured from 2D and 3D images
Multiple secondary outcome variables
Used to describe the cranial shape in more detail
Measured from the 3D image
OCLR is the variable relevant to this presentation – I want you to remember that
We also extracted several secondary variables which describe the cranial shape in more detail – I’ll save you from going through them now as we have little time.

16. Quantifying cranial symmetry
OCLR, ratio between diagnonals, longer divided by shorter x 100% – a higher score indicating a more asymmetrical head shape
A cut-off point that has been established in previous literature
DP was defined as OCLR ≥ 104%
OCLR = a / b x 100%, when a > b. Diagonal difference = a – b, when a > b. Ear offset = c.

17. Quantifying cranial symmetry
Volumetric measurements, not relevant concerning this presentation
ACAI and PCAI = ratios of Anterior and Posterior cuboid volumes, using the formula: (larger cuboid volume – smaller cuboid volume) / smaller cuboid volume x 100%

18. Flowchart
The flowchart – 270 were assessed, 111 randomized and 96 remained for the final analysis

19. Results
The final analysis included 96 infants

20. Font size is small, and hard to see from the back, but that’s intentional – basically this table just shows the background data regarding pregnancy, delivery, newborn cranial shape and neck ROM – no differences.

21. Results
2D-analysis:
11 % in the Intervention Group (IG) and 31 % in the Control Group (CG) had DP at 3 months of age
RR 0.35 (95 % CI 0.14–0.89, p<0.05)
Change in mean OCLR from birth was +0.2 in IG and +1.5 in CG (p<0.01)
3D-analysis:
15 % in IG and 33 % in CG had DP
RR 0.48 (95 % CI 0.22–1.04, p=0.05)
Remember, these are OCLR 104% or more

22. Results 3D-analysis: Asymmetry was milder in the intervention group
In IG, 4.4% had OCLR ≥ 108% and 0% had OCLR ≥ 112%
In CG, 7.8% had OCLR ≥ 108% and 3.9% OCLR ≥ 112% (p<0.05)
IG infants also had a greater ROM (left to right) for lateral flexion at follow-up (103° vs 96°, p<0.05)
When the degree of asymmetry was taken into account (classified as mild, moderate or severe), p < 0.05

23. Conclusions
Preventive instructions regarding infant positioning and care reduce the prevalence and severity of DP, and improve the neck ROM at 3 months
Preventive instructions regarding infant positioning and care, provided right after birth, reduce the…

24. References
Bialocerkowski AE, Vladusic SL, Wei Ng C (2008) Prevalence, risk factors, and natural history of positional plagiocephaly: a systematic review. Dev Med Child Neurol 50:577–586
Cavalier A, Picot MC, Artiaga C, Mazurier E, Amilhau MO, Froye E, Captier G, Picaud JC (2011) Prevention of deformational plagiocephaly in neonates. Early Hum Dev 87:537–543
Hutchison BL, Hutchison LA, Thompson JM, Mitchell EA (2004) Plagiocephaly and brachycephaly in the first two years of life: a prospective cohort study. Pediatrics 114:970–980
Mawji A, Vollman AR, Hatfield J, McNeil DA, Sauve R (2013) The incidence of positional plagiocephaly: a cohort study. Pediatrics 132:298–304
Meyer-Marcotty P, Böhm H, Linz C, Kochel J, Stellzig-Eisenhauer A, Schweitzer T (2013) Three-dimensional analysis of cranial growth from 6 to 12 months of age. Eur J Orthod 36:489–496
Robinson S, Proctor M (2009) Diagnosis and management of deformational plagiocephaly. J Neurosurg Pediatr 3:284–295
van Adrichem LN, van Vlimmeren LA, Cadanova D, Helders PJ, Engelbert RH, van Neck HJ, Koning AH (2008) Validation of a simple method for measuring c ranial de formities (plagiocephalometry). J Craniofac Surg 19:15–21
van Vlimmeren LA, van der Graaf Y, Boere-Boonekamp MM, L’Hoir MP, Helders PJ, Engelbert RH (2007) Risk factors for deformational plagiocephaly at birth and at 7 weeks of age: a prospective cohort study. Pediatrics 119:408–418