Risk Factors for Delayed Diagnosis of Positional Plagiocephaly: A Retrospective Review of 25,322 Patients

Abstract

PURPOSE: Studies of positional plagiocephaly have found that earlier intervention with repositioning in mild cases or a molding orthosis in more severe presentations leads to more effective correction of asymmetry.1,2 However, patients with positional plagiocephaly continue to be misdiagnosed or diagnosed at an older age. This study aims to understand risk factors for late diagnosis of positional plagiocephaly in order to optimize timely intervention. METHODS: After obtaining institutional review board approval, retrospective review was performed of all patients diagnosed with positional plagiocephaly between 2019 and 2019 at a Southern California Kaiser Permanente. Patients were identified with ICD-9 and ICD-10 codes. Those with code descriptions inconsistent with positional plagiocephaly were excluded. Patients were separated into 2 cohorts according to early (≤4 months) or late (>4 months) age of diagnosis. Cohorts were compared for variables including demographics, gestational history, other diagnoses including torticollis or hydrocephalus, and history of hospitalizations in first year of life. Data were queried in Excel (Microsoft Co, Redmond, WA), and statistical analysis using Student’s t test or analysis of variance was performed using SAS (SAS Institute, Carey, NC) with significance denoted at P < 0.05. RESULTS: Twenty-five thousand three hundred thirty-two patients met inclusion criteria. Patients were 61.7% males. 81.5% (n = 20,636) of patients were diagnosed early and 19.5% (n = 4,686) diagnosed late. Patients diagnosed late were significantly more likely to be Hispanic (51.7% versus 46.9%) and less likely to be Asian/Pacific Islander (15.9% versus 20.3%; P < 0.0001). Prematurity (30.5% versus 23.3%; P < 0.0001) and multiple gestation birth (4.9% versus 3.6%; P < 0.0001) were significantly more common in late diagnoses. Patients with plagiocephaly diagnosed late were significantly more likely to have concomitant hydrocephalus (0.6% versus 0.1%; P < 0.0001) and less likely to have torticollis (17.1% versus 21.4%; P < 0.0001). A history of NICU hospitalization (20.8% versus 13.0%; P < 0.001) was associated with late diagnosis and patients diagnosed late spent significantly more days in hospital in the first 3 months of life (6.8 ± 3.4 versus 3.9 ± 6.6 days; P < 0.0001). CONCLUSIONS: Risk factors for late diagnosis of positional plagiocephaly include Hispanic ethnicity, prematurity, multiple gestation birth, or prolonged neonatal hospitalization including NICU stay. Patients with torticollis tend to be diagnosed earlier, suggesting that positional plagiocephaly is easier to diagnose if torticollis is also present. Further education should be provided to pediatricians to screen for positional plagiocephaly, particularly at the 4-month check-up and in patients without torticollis who have other associated risk factors in order to optimize outcomes from conservative treatment or helmet therapy. REFERENCES: 1. Felix K, Tilmann S, JD Kunz, et al. Head orthosis therapy in positional plagiocephaly: influence of age and severity of asymmetry on effect and duration of therapy. Plast Reconstr Surg 2017;140:349–358. 2. Braun T, Hollier LH. Discussion: head orthosis therapy in positional plagiocephaly: influence of age and severity of asymmetry on effect and duration of therapy. Plast Reconstr Surg 2017;140:359–360.