Positional Cranial Deformity Research Articles

Effects of an Educational Intervention Program on Positional Cranial Deformity in Premature Infants.

Positional cranial deformities are associated with prematurity evolving during the first 2 years of life due to the malleable characteristics of the skull, the first year being the main/primary therapeutic window for intervention. The objectives were (a) to describe health characteristics, peri- and postnatal pathologies, and positional cranial deformities in infants enrolled in an early intervention program and (b) to analyze the effects of a parent education-based intervention program on positional cranial deformity in premature infants. A quantitative, analytical, longitudinal study was conducted. It included 103 premature infants enrolled in an early intervention program (EIP) during the year 2017, all under 4 months of corrected age, to whom a parent education-based intervention program was applied. Cranial circumference, cranial width, diagonals, and anteroposterior diameter were measured, and the cranial asymmetry index (CAI) and cephalic index (CI) were calculated at baseline and during two subsequent evaluations separated by a 3-month period. The main results showed that 75.7% of the infants belonged to a very premature gestational age category, and 57.3% had an adequate weight for gestational age. The most frequent pathologies were premature jaundice, premature anemia, and hyaline membrane disease. The most frequent positional cranial deformity was plagiocephaly. The parent education-based intervention program resulted in (1) a significant decrease in the CAI and a significant increase in the IC, (2) plagiocephalies: an increase in the mild category and a decrease in the moderate + severe categories, (3) brachycephalies: a decrease in the absence category and an increase in the moderate + severe category, and (4) dolichocephalies: an increase in the absence category and a decrease in the mild category. In conclusion, the recommended first line of intervention was not enough for this population, and future studies should support the development of national clinical guidelines, where education is complemented with other therapeutic measures.

Positional cranial deformities in preterm infants and their association with health indicators.

To describe positional cranial deformities and peri/postnatal pathologies in preterm infants and to analyze the association between gestational age, birth weight, length of hospitalization, and severity of cranial deformities measured by the Cranial Vault Asymmetry Index (CVAI) and the Cephalic Index (CI). Analytic, cross-sectional study. 103 preterm infants aged under 4 months of corrected age admitted during 2017 to an Early Intervention Program (EIP) were included. Participants were classified according to gestational age as follows: extremely preterm (< 28 weeks), very preterm (28-32 weeks), and moderate-to-late preterm (32-37 weeks). Head circumference, anteroposterior diameter, width, and head diagonals were measured, and the CVAI and CI were calculated. Peri- and postnatal history was obtained from clinical records. 103 preterm infants were evaluated (17 extremely preterm, 78 very preterm, and 8 moderate-to-late preterm). 99 (96.1%) of the preterm infants had positional cranial deformity and, regardless of the degree of prematurity, presented similar cranial anthropometric measurements. Mild plagiocephaly was the most frequent cranial deformity in all groups. We observed a positive association between the days of hospitalization and the CVAI and there was no relationship between the degree of prematurity and the severity of the positional cranial deformation. Most of the patients admitted to the EIP presented positional cranial deformities, mainly mild plagiocephaly, regardless of the degree of prematurity. The presence of plagiocephaly was positively associated with prolonged periods of hospitalization. No relationship was confirmed between the degree of prematurity and the severity of the positional cranial deformity.

Helmet therapy for positional cranial deformations; a 5-year follow-up study

The aim of this study was to assess the long-term effects of helmet therapy in its use for positional cranial deformation, such as plagiocephaly and brachycephaly, by evaluating head shapes in children with a 5-year interval. These children were included at a neonatal age, with a deviating cranial shape classified as positional deformation, and received different forms of therapy, varying from none to physical and helmet therapy combined. Cranial shape was measured before and after therapy, using plagiocephalometry. Both positional plagiocephaly and positional brachycephaly decrease significantly in prevalence and severity over time (P = 0.031 and P < 0.001, respectively), with average relative reductions of 194.5% in ODDI (P = 0.001) and of 878.4% in CPI (P < 0.001). Although the decrease in ODDI and CPI did not significantly vary between treatment methods, ODDI is shown to significantly decrease in case of therapy opposed to no therapy, especially if treatment consists of both physical therapy and helmet therapy (P < 0.001). The long-term effects of therapy are therefore beneficial in the treatment of positional plagiocephaly and will increase the reduction in ODDI, especially in case of both physical and helmet therapy.

Three-Dimensional Quantification of Facial Asymmetry in Children with Positional Cranial Deformity.

The extent of facial involvement in positional plagiocephaly is only little investigated so far. Investigation methods that take into account the challenging anatomical conditions and growth of infants' faces are desirable. In this study, the authors established a new three-dimensional photogrammetry quantification method evaluating pretherapeutic and posttherapeutic facial asymmetry in positional plagiocephaly. Furthermore, a facial asymmetry index was established and evaluated. Three-dimensional photographs of 100 children undergoing treatment with head orthoses were analyzed by constructing a standardized interindividual coordinate system. Defining landmarks, section planes, and point coordinates with a computer-aided design software, both sides of the faces were compared. Facial asymmetry was quantified by measuring differences between left and right sides and pretherapeutic and posttherapeutic changes in each patient. The facial asymmetry index was calculated by putting the absolute differences in relation with the coordinates of the nonaffected side. Present results indicate that positional plagiocephaly results in a distinct facial asymmetry (range, -3.8 to 9.6 mm) in nearly all spatial directions and facial regions. Helmet therapy led to a significant reduction (p < 0.05) of intraindividual facial asymmetry (median change in facial asymmetry index, -1.9 to 3.1 percent). However, no correlation of the Cranial Vault Asymmetry Index and facial asymmetry (Spearman rank correlation coefficient, ρ = -0.09 to 0.47) has been seen. According to these results, severe occipital deformation does not necessarily provoke distinct facial asymmetry. Present three-dimensional photogrammetry method allows the longitudinal quantification of facial involvement in positional plagiocephaly. Asymmetry has been determined in all facial regions. The facial asymmetry decreased through helmet therapy but was not eliminated completely.

Discussion: Three-Dimensional Quantification of Facial Asymmetry in Children with Positional Cranial Deformity.

Discussion: Three-Dimensional Quantification of Facial Asymmetry in Children with Positional Cranial Deformity.

Demographics of Positional Plagiocephaly and Brachycephaly; Risk Factors and Treatment.

In the last 3 decades, the incidence of positional cranial deformations in infants, such as positional plagiocephaly and positional brachycephaly, has increased. The deviating shape often causes parental concern for the later psychosocial wellbeing of the child. Treatment options are nonoperative, varying from positional change to helmet therapy, of which the effect has often been debated. Multiple risk factors have been associated with an increased risk on the development of these deformations. The goal of this study was to assess the impact of known risk factors on the type and severity of resulting positional cranial deformation.Parents were asked to fill out a questionnaire regarding the presence of risk factors, such as gender, age, pregnancy duration, method of delivery and reasons for atypical deliveries, breech position, birth weight, developmental status, positional preference, family history, number of siblings, and torticollis presence. Treatment methods were documented and plagiocephalometry was used to measure the cranial proportions. All children were invited to participate in short-term follow-up. The significance of the risk factors and the effect of different kinds of therapy are discussed. Although no significant correlation was found between severity and risk factors, some risk factors could be correlated with the kind of positional cranial deformation. Of the different therapies, helmet therapy had a significant impact on the reduction of positional plagiocephaly.

Evaluation of positional cranial deformities: the non-expert perspective

The relevance of positional cranial deformity remains a controversial topic. While many specialists support therapeutic intervention with a helmet for severe cases, some are convinced that fears are exaggerated and helmets are unnecessary. In this study, 395 unaffected laypeople were interviewed for their opinion. Standardized photographs of 10 children with different degrees of positional deformity were presented in a randomized order. Values from the literature served as the normal reference (cranial index: 85%; cranial vault asymmetry index: 3.5%). Deformity was regarded as obviously abnormal when at least 50% of the respondents perceived the head as conspicuous. The cut-off value for a therapeutic recommendation was set at 25%. All heads above the reference values were perceived as significantly abnormal by most laypeople, independent of the severity of the deformity. Laypeople saw a need to treat all abnormal infant heads (plagiocephaly: 51.1–72.9%; brachycephaly: 59.5–62.0%; combination: 37.2%). The study results confirmed the existing reference values. Since very mild deformities were perceived as conspicuous and worth treating by the laypeople, the problem is clinically relevant and should not be underestimated. Treatment should therefore be offered regularly. Depending on the severity of the deformity, treatment options may range from conservative therapy (physiotherapy, positioning) to head orthoses in more severe cases.

Positional cranial deformation in children: A plea for the efficacy of the cranial helmet in children

BackgroundCranial deformations have historically aroused the interest of people worldwide. One of the more debated points about positional plagiocephaly is the choice of the treatment. In this article, the senior author (CM) shares his experience on almost 30 years of use of the helmet molding therapy in children with deformation plagiocephaly. Methods and populationWe retrospectively and systematically reviewed the cases of 2188 patients (75% males and 25% females) presenting positional head deformity and treated between 1991 and 2013 with a cranial helmet. To assess the effectiveness of the helmet, we compared the cranial index in bilateral plagiocephaly and the Cranial Diagonals Difference (CDD) in unilateral plagiocephaly at the beginning and at the end of the treatment. ResultsThe cranial indexes ranged between 94.4% and 124.2% before the treatment and decreased significantly between 86.8% and 121.4% after the treatment (P<0.01). The CDD ranged between 0.3 cm and 4.5 cm with an average of 1.50±0.54 cm before the treatment and decreased significantly between 0.1 cm and 2.5 cm with an average of 0.72±0.37 cm after the treatment (P<0.01). For unilateral plagiocephaly, at the beginning of the treatment, 2.5% children presented a mild plagiocephaly, 19.6% a moderate plagiocephaly and 77.9% a severe plagiocephaly. At the end of the treatment, the deformation was classified as mild in 40.2% children, moderate in 44.3% children and severe in 15.5% children with significantly less children in the most severe subgroups (P<0.01) Facial symmetry pre-existed before the treatment in 13.7% of children. This rate was significantly increased at the end of the treatment to 66.7% (P<0.01). In only 8 cases (0.2%), the helmet therapy did not allow to obtain correct clinical results and a surgical posterior cranial remodeling was performed. ConclusionsThe results observed in this series confirms that cranial helmet is a simple and well tolerated alternative which bring satisfying results. Its success implies a good collaboration with parents and a management both by orthoptist, physiotherapist and doctor. Nevertheless, it remains many controversies in the literature concerning in particular long-term cosmetic and functional outcomes. A long-term multicentric prospective study could enable to remove doubts.

Relationship between facial asymmetry and positional plagiocephaly analyzed by three-dimensional computed tomography

PurposeA relationship between positional cranial deformation and facial asymmetry has been suggested; however, details regarding this relationship remain to be clarified. This study aimed to elucidate the relationship between facial asymmetry and positional plagiocephaly using three-dimensional computed tomography (3D-CT). MethodsOne-hundred-and-twenty-nine patients were included, and cranial vault asymmetry index (CVAI) and cephalic index (CI) were used as indicators of positional cranial deformation. Temporal muscle was constructed using 3D-CT data, and its volume was measured. VRL, Me (vertical reference line (VRL)-anterior nasal spine (ANS) and menton (Me) line) angle and the frontal occlusal plane (FOP) angle were measured. ResultsCVAI and VRL, Me angle (R2 = 0.31, P < 0.0001), VRL, Me angle and temporal muscle volume (R2 = 0.13, P < 0.0001), and FOP angle and VRL, Me angle were significantly correlated (R2 = 0.32, P < 0.0001), but CVAI and FOP angle were not (R2 = 0.08). Multiple linear regression analysis indicated that CVAI, FOP angle, and variable temporal muscle volume were significant predictors of VRL, Me angle [(F (5, 123) = 14.94, P < .0001, R2 = 0.38)]. ConclusionsOur results revealed that mandibular deviation was associated with contralateral head slant and ipsilateral increase in temporal muscle volume. Positional plagiocephaly may be a cause of facial asymmetry, and such deviations may occur in the temporal muscle.

The Back to Sleep Campaign, Positional Cranial Deformity, and the Foramen Magnum: New Lessons Learned from Old Pachacamac Crania

In 1992, the American Academy of Pediatrics discouraged prone sleeping positions because of its association with sudden infant death syndrome. The recommendations prompted the United States Public Health Service to begin the “Back to Sleep Campaign,” to promote the habitual practice of placing newborns to sleep in a supine or side‐lying positions. After the Back to Sleep Campaign was initiated, there was a sudden increase in the incidence of deformational plagiocephaly. Therefore, research is warranted regarding effects on the influence of extrinsic forces on the development of the cranium. This study utilized ‘traditional’ and geometric morphometric techniques to compare the foramen magnum size and shape of Peruvian crania from the Samuel George Morton Collection, largely from Pachacamac and likely to have undergone intentional cranial deformation, to those of craniofacially diverse cultures that were not reputed to practice intentional cranial deformation. The results demonstrate statistically significant differences in the sagittal dimension of the foramen magnum between groups. Likewise, geometric morphometric analysis revealed differences in foraminal shapes between groups. The results of this study suggest that extrinsic compressive forces likely alter the structure of the foramen magnum. These findings should be taken into consideration with regard to modern‐day newborn sleeping positions and positional cranial deformation.Support or Funding InformationWV Research Challenge Fund [HEPC.dsr.14.13]

The course of positional cranial deformation from 3 to 12months of age and associated risk factors: a follow-up with 3D imaging.

Deformational plagiocephaly is reported in up to 46.6% of healthy infants, with the highest point prevalence at around 3months of age. Few prospective studies on the natural course of skull deformation have been conducted, and we know of no studies using 3D imaging starting from the highest point prevalence period. In this prospective, population-based cohort study, we describe the course of cranial asymmetry and shape in an unselected population using 3D stereophotogrammetry and investigate factors associated with late cranial deformation and failure to recover from previous deformation. We evaluated 99 infants at 3, 6, and 12months of age. We acquired 3D craniofacial images and performed structured clinical examinations and parental interviews at each visit. Eight outcome variables, representing different aspects of cranial shape, were calculated from a total of 288 3D images. Scores of asymmetry-related variables improved throughout the observation period. However, the rate of correction for cranial asymmetry decreased as the infants grew older, also in relation to the rate of head growth, and a significant amount of asymmetry was still present at 12months. Positional preference at 3months predicted an unfavorable course of cranial asymmetry after 3months, increasing the risk for DP persisting. What is known: • The prevalence of deformational plagiocephaly spontaneously decreases after the first months of life. • Limited neck range of motion and infant positional preference increase the risk of deformational plagiocephaly during the first months of life. What is new: • Positional preference at 3months predicts an unfavorable spontaneous course of deformation also from three to 12months of age, presenting a potential target for screening and treatment. • The spontaneous rate of correction for cranial asymmetry decreases after 6months of age, also in relation to the rate of head growth.

Malocclusion in the primary dentition in children with and without deformational plagiocephaly.

Asymmetries of the jaw and orthodontic abnormalities are suspected as long-term consequences of positional cranial deformity. But only few data exist on this issue. As plagiocephaly is a common problem in infancy, potential functional impairments should be investigated to initiate appropriate measures if necessary. The aim of our study was to compare the orthodontic situation in primary dentition of children with positional plagiocephaly and children without cranial deformities. Fifty children treated by helmet therapy for plagiocephaly and 50 non-affected children (age 1.98-5.69years) were examined in a cross-sectional study. Orthodontic parameters of all dimensions were assessed and analyzed. Children of the plagiocephalic group showed more often orthodontic alterations compared to the others. Especially the frequencies of a class II malocclusion (36 vs. 14%), an edge-to edge bite (28 vs. 12%), and deviations of the midline (38 vs. 16%) were conspicuous. However, none of the differences was significant (p>0.003). Of all observed mandibular asymmetries, 69% appeared as a shift to the contralateral side of the former flattened occipital region. Positional head deformity might be associated in some cases with a higher prevalence of occlusal abnormalities in primary dentition. Positional plagiocephaly interfaces medicine and dentistry. As it is a common disorder, this etiology has to be considered in the prevention and therapy of malocclusion.

Effectiveness of conservative therapy and helmet therapy for positional cranial deformation.

The authors investigated the effectiveness of conservative (repositioning therapy with or without physical therapy) and helmet therapy, and identified factors associated with treatment failure. A total of 4378 patients evaluated for deformational plagiocephaly and/or deformational brachycephaly were assigned to conservative (repositioning therapy, n = 383; repositioning therapy plus physical therapy, n = 2998) or helmet therapy (n = 997). Patients were followed until complete correction (diagonal difference <5 mm and/or cranial ratio <0.85) or 18 months. Rates of correction were calculated, and independent risk factors for failure were identified by multivariate analysis. Complete correction was achieved in 77.1 percent of conservative treatment patients; 15.8 percent required transition to helmet therapy (n = 534), and 7.1 percent ultimately had incomplete correction. Risk factors for failure included poor compliance (relative risk, 2.40; p = 0.009), advanced age (relative risk, 1.20 to 2.08; p = 0.008), prolonged torticollis (relative risk, 1.12 to 1.74; p = 0.002), developmental delay (relative risk, 1.44; p = 0.042), and severity of the initial cranial ratio (relative risk, 1.41 to 1.64; p = 0.044) and diagonal difference (relative risk, 1.31 to 1.48; p = 0.027). Complete correction was achieved in 94.4 percent of patients treated with helmet therapy as first-line therapy and in 96.1 percent of infants who received helmets after failed conservative therapy (p = 0.375). Risk factors for helmet failure included poor compliance (relative risk, 2.42; p = 0.025) and advanced age (relative risk, 1.13 to 3.08; p = 0.011). Conservative therapy and helmet therapy are effective for positional cranial deformation. Treatment may be guided by patient-specific risk factors. In most infants, delaying helmet therapy for a trial of conservative treatment does not preclude complete correction. Therapeutic, III.

Positional cranial deformity—the parents’ point of view

The parents’ point of view regarding positional cranial deformities and helmet therapy has not been the subject of scientific interest yet. However, carer acceptance is a key factor for therapeutic success. We therefore investigated parental perception. The parents of 218 infants were included in a telephone survey; 122 children had undergone helmet therapy and 96 had not. Satisfaction with the outcome, treatment-associated problems, and parental stress were investigated using a structured questionnaire. The great majority (90.8%) of caregivers were satisfied with the outcome, regardless of whether or not helmet therapy was used. Retrospectively, 76% of the parents of infants who had not undergone helmet therapy would decide against helmet therapy again. Therapy was either temporarily stopped (27.0%) or terminated (4.9%) in 31.9% of infants treated with a helmet. Major problems were sweating (51.1%) and skin lacerations (30.9%). The parents indicated minor (54.9%) or even great (25.4%) personal strain. Conflict with others (38.5%), stress for the child (30.3%), and a financial burden (36.9%) were mentioned most frequently. There appear to be more parental problems than expected associated with helmet therapy. Medical experts should take this into consideration. The indication for a helmet should be evaluated critically and the potential parental burdens should be addressed during counselling.

Preclinical pathways to treatment in infants with positional cranial deformity

Positional plagiocephaly in infants is frequent. As well as positioning, physiotherapy, and osteopathy, helmet therapy is an effective treatment option. The outcome also depends on the timely initiation of treatment. We investigated the preclinical pathways to treatment. Parents of 218 affected children were interviewed. Data were collected regarding detection and the treatments used prior to the first craniofacial consultation at the study clinic in Germany. Descriptive and statistical analyses were performed. For 78.4% of the children, the cranial deformities were first detected at ≤4 months of age. One hundred and twenty-two children received helmet therapy. Parents consulted the paediatrician with a mean latency of 0.4 months; 3.3 months passed until the first craniofacial consultation. Approximately 90% were treated with repositioning and 75.2% received additional physiotherapy or osteopathy prior to presentation. Children treated with physiotherapy/osteopathy presented significantly later (P=0.023). The time lapse to craniofacial consultation was not significantly different between children with and without later helmet therapy. We identified a relevant delay between the detection of positional cranial deformity and consultation with a craniofacial specialist. For affected children, this may potentially compromise the outcome of helmet therapy. Early referral to a specialist and if necessary the simultaneous application of different treatments should be preferred.

A Prospective Randomized Trial on Preventative Methods for Positional Head Deformity: Physiotherapy versus a Positioning Pillow

To evaluate the impact of stretching exercises versus available bedding pillows on positional head deformities. Fifty children aged 5 months or younger with positional head deformity were included in this prospective clinical trial (n=20 plagiocephaly, n=10 brachycephaly, n=20 combination). A random distribution was performed for treatment with the bedding pillow alone (n=25) or with stretching exercises (n=25) for 6 weeks. Anthropometric caliper measurements were done before and after that interval. Cranial vault asymmetry index (CVAI) and cranial index (CI) were calculated and analyzed using a descriptive statistical general linear model. ΔCVAI in the stretching group was 2.09% for plagiocephaly and 2.34% for combined head deformities. Using the bedding pillow, ΔCVAI was 3.01% in plagiocephal children and 2.86% for combined head deformity. The ΔCI in the stretching group was 0.94% for isolated brachycephal children and 2.24% for combined head deformity. ΔCI in the pillow group was 3.63% for brachycephaly and 3.23% in children with combined head deformities, respectively. Bedding pillows and stretching exercises both resulted in improvements in positional cranial deformation. For children with combined plagiocephaly and brachycephaly, improvement in cranial asymmetry was slightly greater when using bedding pillows versus stretching.

Clinical classification of positional cranial deformity: a statistical analysis

Clinical classification of positional cranial deformity: a statistical analysis

Complications in helmet therapy

ObjectiveHelmet therapy is an established method to correct positional head deformity in early infancy. Side effects such as skin erythema or pressure sores are well known for helmet therapy, but not yet adequately discussed in current literature. Patients and methodsRetrospectively, all patient-sheets of infants treated by individual orthotic therapy in the years 2007 and 2008 were sighted and complications were noted. Complications were classified and sorted by their frequency and descriptive statistics was performed. The treatment to cure complications was recorded and success in complication control was analysed. ResultsAltogether, 410 patients fit the inclusion criteria for this investigation. Complications were apportioned into pressure sores, local ethanol erythema, unsatisfying fit of the helmet or loss of the helmet, skin infection, failed correction of head deformity, and subcutaneous abscess in one case. Non-compliance is to be noticed in a high number, but mainly occurred towards the end of the treatment period. ConclusionHelmet therapy represents a safe therapeutic tool for the correction of positional cranial deformity. Complications have to be clear in number and severity for parental elucidation. Most complications can easily be avoided or eliminated by proper instruction of the parents.

Value and reliability of anthropometric measurements of cranial deformity in early childhood

Objectives Since the “back to sleep” campaign initiated by the American Pediatric Society in 1992, an increasing incidence of positional cranial deformity in early infancy has been widely observed. Anthropometric caliper measurements present the most practical tool for diagnosis and decision making although their value is being controversially discussed in literature. Patients and methods Our study included 30 randomly chosen infants who had been diagnosed with plagiocephaly, brachycephaly, or a combination of both conditions. The 10 patients in each group were then measured anthropometrically by three examiners. The following parameters were measured six times in a standard manner and with a standard head position by each examiner: circumference, length, width, and oblique distance from the fronto-temporal area (ft) to the lambdoid suture on each side of the head (ld). Inter- and intra-observer variabilities for every value were statistically evaluated by a variance components estimation procedure. Results Both inter- and intra-observer agreement had very low variability. Overall, mean inter-observer variability was lower than 0.182 mm 2, and mean intra-observer variability was lower than 1.131 mm 2. Altogether, interobserver variability as well as intraobserver variability had a maximum of about 2 mm measurement variance. Conclusions Standardized measurements are highly reproducible to quantify early childhood head deformity. Standard head position is indispensable for reliable measurement. Repeatability of anthropometric measurements is essential to define diagnoses and severity codes and to develop treatment concepts.