Best Practice for Conservative Management of Plagiocephaly

What is Plagiocephaly?? “skewed head” Mechanical factors alter head shape Post natal positioning of infant on same side of head Parallelogram

Incidence: ‘Back to Sleep” campaign: SIDS Incidence of SIDS reduced from 2.6/1000 in 1986 to 1/1000 in 1998 Incidence of plagiocephaly has increased from 1/300 to 1/60 between 1974 and 1996 Increase in referrals to PT

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 who are seen through the EIP Program Ensure knowledge transfer occurs to clinicians at QACCH

Literature Review: 1 Systematic Review: Bialocerowski et al reviewed all research reports related to conservative management between Jan 1983 and December Of 16 studies in the review, none were RCT’s. ie Level I evidence All were case series or comparison studies, not randomly assigned, ie. Level III or IV. Considerable biases were present within each study Quality of studies was poor to moderate Conservative treatments: counter-positioning +/- physiotherapy, physiotherapy, and helmet therapy

Bialocerkowski et al: Conclusions Counter positioning +/- physiotherapy or helmet therapy can reduce positional plagiocephaly Need for standard outcome measure (reliable and valid) Parent perception of cosmetic appearance should be reflected in outcome measure

Bialocerkowski: results cont. Discrepancy between studies, some found helmetting more effective, some found counter positioning as effective Studies varied in age treatment started, assessment methods, severity, incomplete data on children lost, outcome measures

Lit review: other authors Graham et al, 2005, reviewed by EBP group as a moderate quality study (9/16), level III LOE Both repositioning and helmet therapy work when used appropriately, with neck physiotherapy Found helmet therapy slightly more effective( 61% reduction, vs. 52%) Early helmetting before 8 months more effective than later Limitations: lack of random assignment and significance of outcome measures

Lit review: other authors Bruner et al, 2004, scored 8/16 on review by EBP group, level IV LOE Assessed changes due to helmetting, using computer tomography Found 36-39% reduction in cranial asymmetry in compliant children Results not reported on more than one half of subjects, either lost to follow-up or non-compliant

Comments: In many of the studies there was lack of random assignment because of the existing standard of practice that a moderate to severe plagiocephaly is referred for helmetting after 6/7 months of age Many authors note that counter positioning becomes less effective after about 6 months of age, as infants become more mobile

Counter positioning If your baby has a flat spot, turn your baby slightly off his or her back at about a 45 degree angle. This will take the pressure off the flat spot. Use a crib roll to prevent your baby from rolling onto the tummy. Continue with this new position to keep your baby off the flat spot until your baby's skull becomes round and even.

Repositioning varied between studies Caregivers instructed in: “Never allow infant to sleep on flat spot” Position interest on non flattened side Adjust carry, hold, feeding positions Active head turning incorporated in play Adjust/ minimize time in baby seats/car seats Early supervised tummy time

Helmet Therapy In infants with moderate to severe plagiocephaly, parents will be given information that helmetting may be beneficial

Comments re helmetting: Expense and travel Hot, sweaty, skin injury Brachycephalic children hard to fit Lack of infant acceptance, more so in older infants Parent embarrassment

Associated torticollis Differentiation between sternocleidomastoid imbalance and contracture Golden et al, in 1999, found 64% of infants with PP had SCM imbalance, 12% contracture Early detection and treatment of SCM involvement may potentially lessen or prevent craniofacial deformity There was variability in studies with the provision of PT or specific techniques used There are a series of studies related to PT in tort.

Determinants: Predominantly male: 60-70% Predominantly right-sided Caucasian Increased incidence associated with: multi-parity Prematurity Breech delivery

Determinants: Higher prevalence of PP found in children that: Sleep on their back Don’t have head position varied Spend less than 5 minutes/day in prone Are always bottle fed with same hand

Prevention: Most authors stress the importance of prevention in reducing this new epidemic of PP Counseling of parents to newborns should include: Alternating head position Tummy time for more than 5 minutes per day (supervised) Minimizing time in car seats/seats Changing orientation to outside activities

Associated Problems: There is some evidence of increased incidence of the following in infants with PP: Scoliosis, rib, hip, foot problems Visual disturbances (strabismus, astigmatism, field defects) Subtle developmental delay The cause/effect relationship of these is unclear.

EIP Physiotherapy Plans: Protocol for assessment and intervention being developed by PT’s, incorporating the evidence found in this review Parent handouts to be developed/chosen Prevention is the most effective intervention. We need to ensure this information is available to other health care workers, particularly those involved in post natal care.