Factors influencing outcomes of the treatment of positional plagiocephaly in infants: a 7-year experience

Abstract

<jats:sec> <jats:title>OBJECTIVE</jats:title> <jats:p>Following institution of the Back to Sleep Campaign, the incidence of sudden infant death syndrome decreased while the prevalence of positional skull deformation increased dramatically. The management of positional deformity is controversial, and treatment recommendations and outcomes reporting are variable. The authors reviewed their institutional experience (2008–2014) with the treatment of positional plagiocephaly to explore factors associated with measured improvement.</jats:p></jats:sec> <jats:sec> <jats:title>METHODS</jats:title> <jats:p>A retrospective chart review was conducted with risk factors and treatment for positional head shape deformity recorded. Univariate and multivariate analyses were used to assess the impact of these variables on the change in measured oblique diagonal difference (ODD) on head shape surface scanning pre- and posttreatment.</jats:p></jats:sec> <jats:sec> <jats:title>RESULTS</jats:title> <jats:p>A total of 991 infants aged less than 1 year were evaluated for cranial positional deformity in a dedicated clinical program. The most common deformity was occipital plagiocephaly (69.5%), followed by occipital brachycephaly (18.4%) or a combination of both deformities (12.1%). Recommended treatment included repositioning (RP), physical therapy (PT) if indicated, or orthotic treatment with a customized cranial orthosis (CO) according to an age- and risk factor–dependent algorithm that the authors developed for this clinic. Of the 991 eligible patients, 884 returned for at least 1 follow-up appointment. A total of 552 patients were followed to completion of their treatment and had a full set of records for analysis: these patients had pre- and posttreatment 2D surface scanner evaluations. The average presenting age was 6.2 months (corrected for prematurity for treatment considerations). Of the 991 patients, 543 (54.8%) had RP or PT as first recommended treatment. Of these 543 patients, 137 (25.2%) transitioned to helmet therapy after the condition did not improve over 4–8 weeks. In the remaining cases, RP/PT had already failed before the patients were seen in this program, and the starting treatment recommendation was CO. At the end of treatment, the measured improvements in ODD were 36.7%, 33.5%, and 15.1% for patients receiving CO, RP/PT/CO, and RP/PT, respectively. Univariate analysis showed that sex, race, insurance, diagnosis, sleep position preference, torticollis history, and multiple gestation were not significantly associated with magnitude of ODD change during treatment. On multivariate analysis, corrected age at presentation and type of treatment received were significantly associated with magnitude of ODD change. Orthotic treatment corresponded with the largest ODD change, while the RP/PT group had the least change in ODD. Earlier age at presentation corresponded with larger ODD change.</jats:p></jats:sec> <jats:sec> <jats:title>CONCLUSIONS</jats:title> <jats:p>Earlier age at presentation and type of treatment impact the degree of measured deformational head shape correction in positional plagiocephaly. This retrospective study suggests that treatment with a custom CO can result in more improvement in objective measurements of head shape.</jats:p></jats:sec>

Helmet Treatment of Infants With Deformational Brachycephaly

“…For infants beginning treatment between 3.0 and 4.5 months of age, reduction in cephalic index was 5.1%; for infants 4.5 to 6.0 months of age, it was 3.2%; and for infants entering treatment later than 6 months, reduction in cephalic index was 2.9%. These results mirror the findings of other investigators who have previously reported on the positive impact of early entrance age on the effectiveness of the cranial orthosis 37 , 44 - 52 ( Table 6 ).…”

“…The most immediate limitation is that this is not, nor was it designed to be, a randomized control trial. While many authors have previously discussed why execution of a randomized control trial may be difficult or even ethically questionable, 52 - 54 it was simply not within our scope to be able to perform. As a medical treatment provider, patients are sent by physicians who have diagnosed and monitored their patients and have prescribed treatment based on their dissatisfaction with the progression of head shape.…”

The health belief model and factors associated with adherence to treatment recommendations for positional plagiocephaly

“…(See Fig. 2 in the related article by Lam et al 8 ). We included patients younger than 12 months of age at presentation with a diagnosis of occipital brachycephaly, occipital plagiocephaly, or both, who had a documented recommended treatment plan.…”

“…Adherence was recorded according to parental report on details of treatment at the time of each clinic visit. Our treatment algorithm and rationale are described in a related paper by Lam et al 8 This study received approval from the Baylor College of Medicine institutional review board.…”

“…Physical or occupational therapy is recommended when torticollis is the underlying cause of positional deformity. 8 If these conservative measures are not effective, a custom cranial orthosis may be placed to aid in the correction of the deformity. 13 The cranial orthosis takes advantage of the rapid rate of brain growth in normal infants and may modulate skull shaping by fitting closely to the head to prevent pressure on one area while still leaving room for preferential directed growth at the flattened area.…”