Positional PlagiocephalyThe Shape of Affairs

November 21, 2009

Patricia MortensonDr. P. SteinbokAlan Keith

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

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

PLAGIOCEPHALY?

“oblique head” Causes

– Deformational forces on moldable skull– Nature of the infant skull– Uterine & post-natal positioning– Gravitational forces– Correlation with torticollis

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)

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)

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)

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

TYPES

Occipital Positional Plagiocephaly

www.plagiocephaly.org

Unilateral occipital flattening Ear may be forward (Ipsilateral) Forehead and cheek may be forward (Ipsilateral)

Brachycephaly

www.plagiocephaly.org

Bilateral occipital flattening Side of head widened

Positional Scaphocephaly

www.plagiocephaly.org

Long and narrow head More common in premature babies

ASSESSMENT & TREATMENT

HISTORY

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

HISTORY

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

CLINICAL ASSESSMENT

View from top, back, sides, front

CLINICAL ASSESSMENT

Describe shape of head

CLINICAL ASSESSMENT

CLINICAL ASSESSMENT

Eye symmetry & shape When in doubt refer to neurosurgery

Clinical Assessment

Check head turning and tilt

If possible, assess in sitting, supine & prone

? HOW TO QUANTIFY

Measurement

Challenges:– 2D measures on 3D

object– Squirmy subjects

Variety of methods:– Visual ratings– Anthropometric

(caliper measures)– Digital photos – CT scan– Laser scanner

Measurement Issues

Issues with– Classification– Reliability– Cost– Radiation & Sedation

(Mortenson & Steinbok, 2006)

Need standardized classification system (McGarry et al., 2008)

For now….

Argenta’s clinical classification

Severity assessment sheets available at: www.cranialtech.com – ? Reliability / validity

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

bossingArgenta, 2004

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

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)

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

TREATMENT

TREATMENT - Positioning

Rapid head growth Positioning for

prevention and treatment

Reverse process

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

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.”

www.cps.ca/english/statements/IP/cps98-01.htm#sleep

POTENTIAL PRODUCTS

Safe T Sleep www.safetsleep.com

Not approved by CPA

Cautious use, Hutchison et al., 2007

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

UPRIGHT

Use of carriers Hip belts & wide

straps

Ergo carrier

Baby Trecker

PLAY POSITION

Awake & up Tummy timeSupported sittingSide lying for play

TUMMY TIME

Start with short but FREQUENT times

Options include:– On chest– Over legs– Supported on Floor

TUMMY TIME TEACHING

BE: Encouraging Realistic Demonstrate on

baby OR doll

BUMBO

•Not all babies tolerate

•never use on an elevated surface•supervise•www.bumbosafety.com

SIDE LYING

On Round side Best for pre-rollers

Rolled blankets “Sleep” positioning devices

FEEDING POSITION

Bottle feed from “round” side

Feed from “round” side in highchair

BABY EQUIPMENT

Car seat stays in car Stroller 101 Limit Swing Use Good equipment

IMPORTANT FACTORS

Multiple options for caregivers Realistic Demonstration as needed

Address any developmental factors

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

TREATMENT – Other issues

Torticollis – need to treat– Positioning not as effective

(Losee et al., 2007)

Motor & Developmental delays

Parental guilt

OUTCOMES & SEQUELAE

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)

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

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

Head banding – long term f/u

Changes post head band are stable at 5 years post treatment

(Lee et al., 2008)

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

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

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)

SEQUELAE

Not well studied Weak evidence

Many claims unsubstantiated:– Migraines– Vision problems

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)

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)

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)

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

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

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)

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

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

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

PARENTAL CONCERN

Awareness vs. Information overload fueling consumer drive

TV, newspaper and magazine stories Parent support networks, chat groups

– www.cappskids.org

Commercial products

WHAT WE ARE DOING IN BC

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

BCCH PROGRAM

OT Plagiocephaly Clinic

Parent education group with individual assessment

Concurrent with Torticollis & Neurosurgery clinics

4 new patients/wk, 2 follow-ups

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.

BCCH PROGRAM

Small program (0.1 FTE) Impact of over referrals

– No need to refer mild cases

Other Health Regions

Families outside lower mainland not well served

Often sent down inappropriately or too late

Opportunities for collaboration & regional clinics

WITHIN BC - Headbands

Valley Orthocare Scanner?

No MSP coverage for headbands– Pharmacare– Ministry– Extended Health Plans

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

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)

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)

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

RESOURCES

Clinician’s Guide available Coming - Caregivers’ Guide

Reference list

Websites with cautionwww.cheo.on.cawww.sickkids.ca – search plagiocephalywww.plagiocephaly.orgwww.cranialtech.comwww.cappskids.org

Comments? Questions?