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

13. ASSESSMENT & TREATMENT

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

18. CLINICAL ASSESSMENT

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

32. TREATMENT

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

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
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
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
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

49. OUTCOMES & SEQUELAE

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

68. WHAT WE ARE DOING IN BC

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?