Diagnosis and management of deformational plagiocephaly

A review

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  • 1 Departments of Neurological Surgery and Neurosciences, Rainbow Babies & Children's Hospital, Case Western Reserve University School of Medicine, Cleveland, Ohio; and
  • | 2 Department of Neurological Surgery, Children's Hospital, Harvard Medical School, Boston, Massachusetts
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Object

The increase in the prevalence of nonsynostotic occipital deformational plagiocephaly in infants, which resulted from the American Academy of Pediatrics' 1992 recommendation to have healthy infants sleep supine, has been accompanied by significant controversy in diagnosis and management. The controversy was exacerbated by the 1998 FDA classification of cranial orthotic devices as Class II devices requiring premarket notification, and the subsequent increase in treatment-associated costs.

Methods

Two independent reviews of the literature were conducted to clarify the objective evidence available within the context of pediatric craniofacial knowledge.

Results

. Although deformational plagiocephaly is not a life-threatening problem, it is a source of disfigurement for children that may be detrimental to their well-being. Current methods for quantifying the degree of disfigurement have limited interrater reliability, and no prospective randomized controlled trials comparing the efficacy of cranial orthoses to repositioning and physical therapy protocols have been published. Despite this lack of Class I evidence, cranial orthoses are routinely and effectively used to treat persistent severe deformational plagiocephaly. The need for the current FDA regulations has not been supported by clinical experience and reported complications.

Conclusions

This review resulted in the following recommendations: 1) more parental education is needed to minimize the development and progression of deformational plagiocephaly; 2) mild deformity can be treated with repositioning and physical therapy protocols; and 3) severe deformity is likely to be corrected more quickly and effectively with cranial orthosis (when used during the appropriate period of infancy) than with repositioning and physical therapy. The available data do not support the need for FDA classification for cranial orthoses as Class II devices requiring premarket notification. Removal of the regulations, which centralized production of the orthoses to larger companies and markedly increased charges, will probably eliminate much of the controversy and parental anxiety generated by marketing strategies.

Abbreviations used in this paper:

AAP = American Academy of Pediatrics; CVA = cranial vault asymmetry; MDI = Mental Developmental Index; OFC = orbitofrontal head circumference; PDI = Psychomotor Developmental Index; SIDS = Sudden Infant Death Syndrome.

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Contributor Notes

Address correspondence to: Shenandoah Robinson, M.D., Department of Pediatric Neurosurgery, Rainbow Babies & Children's Hospital, B501, 11100 Euclid Avenue, Cleveland, Ohio 44106. email: Shenandoah.robinson@UHhospitals.org.
  • 1

    American Academy of Pediatrics Task Force on SIDS: The changing concept of sudden infant death syndrome: diagnostic coding shifts, controversies regarding the sleeping environment, and new variables to consider in reducing risk. Pediatrics 116:12451255, 2005

    • Search Google Scholar
    • Export Citation
  • 2

    American Academy of Pediatrics Task Force on Infant Sleep Positioning and SIDS: Changing concepts of sudden infant death syndrome: implications for infant sleeping environment and sleep position. Pediatrics 105:650656, 2000

    • Search Google Scholar
    • Export Citation
  • 3

    American Academy of Pediatrics Task Force on Infant Sleep Positioning and SIDS: Positioning and SIDS. Pediatrics 89:11201126, 1992

  • 4

    Argenta L: Clinical classification of positional plagiocephaly. J Craniofac Surg 15:368372, 2004

  • 5

    Bhushan V, & Paneth N: The reliability of neonatal head circumference measurement. J Clin Epidemiol 44:10271035, 1991

  • 6

    Bialocerkowski A, , Vladusic S, & Howell S: Conservative interventions for positional plagiocephaly: a systematic review. Dev Med Child Neurol 47:563570, 2005

    • Search Google Scholar
    • Export Citation
  • 7

    Boere-Boonekamp M, & van der Linden-Kuiper L: Postional preference: prevalence in infants and follow-up after two years. Pediatrics 107:339343, 2001

    • Search Google Scholar
    • Export Citation
  • 8

    Clarren S: Plagiocephaly and torticollis: etiology, natural history, and helmet treatment. J Pediatr 98:9295, 1981

  • 9

    Collett B, , Breiger D, , King D, , Cunningham M, & Speltz M: Neurodevelopmental implications of “deformational” plagiocephaly. J Dev Behav Pediatr 26:379389, 2005

    • Search Google Scholar
    • Export Citation
  • 10

    Cunningham M, & Heike C: Evaluation of the infant with an abnormal skull shape. Curr Opin Pediatr 19:645651, 2007

  • 11

    Davis B, , Moon R, , Schas H, & Ottolini M: Effects of sleep position on infant motor development. Pediatrics 102:11351140, 1998

  • 12

    de Ribaupierre S, , Vernet O, , Rilliet B, , Cavin B, , Kalina D, & Leyuraz PF: Posterior positional plagiocephaly treated by cranial remodelling orthosis. Swiss Med Wkly 137:368372, 2007

    • Search Google Scholar
    • Export Citation
  • 13

    de Chalain T, & Park S: Torticollis associated with positional plagiocephaly: a growing epidemic. J Craniofac Surg 16:411418, 2005

  • 14

    Ellenbogen R, , Gruss J, & Cunningham M: Update on craniofacial surgery: the differential diagnosis of lambdoid synostosis/posterior plagiocephaly. Clin Neurosurg 47:303318, 2000

    • Search Google Scholar
    • Export Citation
  • 15

    Fowler E, , Becker D, , Pilgram T, , Noetzel M, , Epstein J, & Kane A: Neurologic findings in infants with deformational plagiocephaly. J Child Neurol 23:742747, 2008

    • Search Google Scholar
    • Export Citation
  • 16

    Govaert B, , Michels A, , Colla C, & van der Hulst R: Molding therapy of positional plagiocephaly: subjective outcome and quality of life. J Craniofac Surg 19:5658, 2008

    • Search Google Scholar
    • Export Citation
  • 17

    Graham JM Jr, , Gomet M, , Halberg A, , Earl D, , Kreutzman J, & Cui J, et al. : Management of deformational plagiocephaly: repositioning versus orthotic therapy. J Pediatr 146:258262, 2005

    • Search Google Scholar
    • Export Citation
  • 18

    Hellbusch J, , Hellbusch L, & Bruneteau R: Active counter-positioning of deformational occipital plagiocephaly. Nebr Med J 86:344349, 1995

    • Search Google Scholar
    • Export Citation
  • 19

    Hutchison B, , Hutchison L, , Thompson J, & Mitchell E: Plagiocephaly and brachycephaly in the first two years of life: a prospective cohort study. Pediatrics 114:970980, 2004

    • Search Google Scholar
    • Export Citation
  • 20

    Jalaluddin M, , Moss D, & Shaffon D: Occipital plagiocephaly: the treatment of choice. Neurosurgy 49:545, 2001. (Abstract)

  • 21

    Jantz J, , Blosser C, & Fruechting L: A motor milestone change noted with a change in sleep position. Arch Pediatr Adolesc Med 151:565568, 1997

    • Search Google Scholar
    • Export Citation
  • 22

    Johnson TS, , Engstrom JL, & Gelhar DK: Intra- and interexaminer reliability of anthropometric measurements of term infants. J Pediatr Gastroenterol Nutr 24:497505, 1997

    • Search Google Scholar
    • Export Citation
  • 23

    Kelly K, , Littlefield T, , Pomatto J, , Manwaring K, & Beals S: Cranial growth unrestricted during treatment of deformational plagiocephaly. Pediatr Neurosurg 30:193199, 1999

    • Search Google Scholar
    • Export Citation
  • 24

    Kordestani R, , Patel S, , Bard D, , Gurwitch R, & Panchal J: Neurodevelopmental delays in children with deformational plagiocephaly. Plast Reconstr Surg 117:207218, 2006

    • Search Google Scholar
    • Export Citation
  • 25

    Lee R, , Teichgraeber J, , Baumgartner J, , Waller A, , English P, & Lasky R, et al. : Long-term treatment effectiveness of molding helmet therapy in the correction of posterior deformational plagiocephaly: a five-year follow-up. Cleft Palate Craniofac J 45:240245, 2008

    • Search Google Scholar
    • Export Citation
  • 26

    Lee W, , Richards K, , Redhed J, & Papay F: A pneumatic orthotic cranial molding helmet for correcting positional plagiocephaly. J Craniofac Surg 17:139144, 2006

    • Search Google Scholar
    • Export Citation
  • 27

    Littlefield TR, , Beals SP, , Manwaring KH, , Pomatto JK, , Joganic EF, & Golden KA, et al. : Treatment of craniofacial asymmetry with dynamic orthotic cranioplasty. J Craniofac Surg 9:1117, 1998

    • Search Google Scholar
    • Export Citation
  • 28

    Littlefield T, , Kelly K, , Pomatto J, & Beals S: Multiple-birth infants at higher risk for development of deformational plagiocephaly. Pediatrics 103:565570, 1999

    • Search Google Scholar
    • Export Citation
  • 29

    Littlefield T, , Pomatto J, & Kelly K: Dynamic orthotic cranioplasty: treatment of the older infant. Report of four cases. Neurosurg Focus 9:3 E5, 2000

    • Search Google Scholar
    • Export Citation
  • 30

    Liu Y, , Kadlub N, , da Silva Freitas R, , Persing J, , Duncan C, & Shin C: The misdiagnosis of craniosynostosis as deformational plagiocephaly. J Craniofac Surg 19:132136, 2008

    • Search Google Scholar
    • Export Citation
  • 31

    Losee J, , Mason A, , Dudas J, , Hua L, & Mooney M: Nonsynostotic occipital plagiocephaly: factors impacting onset, treatment, and outcomes. Plast Reconstr Surg 119:18661873, 2007

    • Search Google Scholar
    • Export Citation
  • 32

    Loveday B, & de Chalain T: Active counterpositioning or orthotic device to treat positional plagiocephaly. J Craniofac Surg 12:308313, 2001

    • Search Google Scholar
    • Export Citation
  • 33

    Majnemer A, & Barr R: Influence of supine sleep positioning on early motor milestone acquisition. Dev Med Child Neurol 47:370376, 2005

  • 34

    McGarry A, , Dixon MT, , Grieg RJ, , Hamilton DR, , Sexton S, & Smart H: Head shape measurement standards and cranial orthoses in the treatment of infants with deformational plagiocephaly: a systematic review. Dev Med Child Neurol [epub ahead of print] 2008

    • Search Google Scholar
    • Export Citation
  • 35

    McKinney C, , Cunningham M, , Holt V, , Lerous B, & Starr J: Characteristics of 2733 cases diagnosed with deformational plagiocephaly and changes in risk factors over time. Cleft Palate Craniofac J 45:208216, 2008

    • Search Google Scholar
    • Export Citation
  • 36

    Miller R, & Clarren S: Long-term developmental outcomes in patients with deformational plagiocephaly. Pediatrics 105:15, 2000

  • 37

    Mortenson O, & Steinbok P: Quantifying positional plagiocephaly: reliability and validity of anthropometric measurements. J Craniofac Surg 17:413419, 2006

    • Search Google Scholar
    • Export Citation
  • 38

    Moss S: Nonsurgical, nonorthotic treatment of occipital plagiocephaly: what is the natural history of the misshapen neonatal head?. J Neurosurg 87:5 Suppl 667670, 1997

    • Search Google Scholar
    • Export Citation
  • 39

    Mulliken J, , Vander Woude D, , Hansen M, , LaBrie R, & Scott R: Analysis of posterior plagiocephaly: deformational versus synostotic. Plast Recontr Surg 103:371389, 1999

    • Search Google Scholar
    • Export Citation
  • 40

    National Health Service (QIS): The Use of Cranial Orthosis Treatment for Infant Deformational Plagiocephaly Edinburgh, UK, National Health Service Quality Improvement Scotland, 2007. (http://www.nhshealthquality.org/nhsqis/files/Infant%20plagiocephaly%20final%20May%202007.pdf) [Accessed 12 January 2009]

    • Search Google Scholar
    • Export Citation
  • 41

    O'Broin E, , Allcutt D, & Earley M: Posterior plagiocephaly: proactive conservative management. Br J Plast Surg 52:1823, 1999

  • 42

    Paine R: Neurologic conditions in the neonatal period. Pediat Clin North Am 8:577610, 1961

  • 43

    Panchal J, , Amirsheybani H, , Gurwitch R, , Cook V, , Francel P, & Neas B, et al. : Neurodevelopment in children with single-suture craniosynostosis and plagiocephaly without synostosis. Plast Reconstr Surg 108:1149211498, 2001

    • Search Google Scholar
    • Export Citation
  • 44

    Peitsch W, , Keefer C, , LaBrie R, & Mulliken J: Incidence of cranial asymmetry in healthy newborns. Pediatrics 110:18, 2002

  • 45

    Persing J, , James H, , Swanson J, & Kattwinkel J: Prevention and management of positional skull deformities in infants. Pediatrics 112:199202, 2003

    • Search Google Scholar
    • Export Citation
  • 46

    Plank L, , Giavedoni B, , Lombardo J, , Geil M, & Reisner A: Comparison of infant head shape changes in deformational plagiocephaly following treatment with a cranial molding orthosis using a noninvasive laser shape digitizer. J Craniofac Surg 17:10841091, 2006

    • Search Google Scholar
    • Export Citation
  • 47

    Pollack I, , Losken H, & Fasick P: Diagnosis and management of posterior plagiocephaly. Pediatrics 99:180185, 1997

  • 48

    Regelsberger J, , Delling G, , Tsokos M, , Helmke K, , Kammler G, & Kranzlein H, et al. : High-frequency ultrasound confirmation of positional plagiocephaly. J Neurosurg 105:5 Suppl 413417, 2006

    • Search Google Scholar
    • Export Citation
  • 49

    Rekate H: Occipital plagiocephaly: a critical review of the literature. J Neurosurg 89:5 Suppl 2430, 1998

  • 50

    Rogers GF, , Miller J, & Mulliken JB: Comparison of a modifiable cranial cup versus repositioning and cervical stretching for the early correction of deformational posterior plagiocephaly. Plast Reconstr Surg 121:941947, 2008

    • Search Google Scholar
    • Export Citation
  • 51

    Saeed N, , Wall S, & Dhariwal D: Management of positional plagiocephaly. Arch Dis Child 93:8284, 2008

  • 52

    Scruton D: Position as a cause of deformity in children with cerebral palsy (1976). Dev Med Child Neurol 50:404, 2008

  • 53

    Siatkowski R, , Fortney A, , Nazir S, , Cannon S, , Panchal J, & Fancel P, et al. : Visual field defects in deformational posterior plagiocephaly. J AAPOS 9:274278, 2005

    • Search Google Scholar
    • Export Citation
  • 54

    Sim J, & Wright C: The Kappa statistic in reliability studies: use, interpretation, and sample size requirements. Phys Ther 85:257268, 2005

    • Search Google Scholar
    • Export Citation
  • 55

    Spermon J, , Spermon-Marijen R, & Scholten-Peeters W: Clinical classification of deformational plagiocephaly according to Argenta: a reliability study. J Craniofac Surg 19:664668, 2008

    • Search Google Scholar
    • Export Citation
  • 56

    Stallings M, , Rappo P, & Lanzkowsky S: Comment on Persing J, James H, Swanson J, et al: Prevention and management of positional skull deformities in infants. Pediatrics 113:422424, 2004

    • Search Google Scholar
    • Export Citation
  • 57

    Steinbok P, , Lam D, , Singh S, , Mortenson P, & Singhal A: Longterm outcome of infants with positional occipital plagiocephaly. Childs Nerv Syst 23:12751283, 2007

    • Search Google Scholar
    • Export Citation
  • 58

    Stellwagen L, , Hubbard E, , Chambers C, & Jones K: Torticollis, facial asymmetry, and plagiocephaly in normal newborns. Arch Dis Child 93:827831, 2008

    • Search Google Scholar
    • Export Citation
  • 59

    Sze R, , Parisi M, , Sidhu M, , Paladin A, , Ngo AV, & Seidel K, et al. : Ultrasound screening of the lambdoid suture in the child with posterior plagiocephaly. Pediatr Radiol 33:630636, 2003

    • Search Google Scholar
    • Export Citation
  • 60

    Teichgraeber J, , Seymour-Dempsey K, , Baumgartner J, , Xia J, , Waller A, & Gateno J: Molding helmet therapy in the treatment of brachycephaly and plagiocephaly. J Craniofac Surg 15:118123, 2004

    • Search Google Scholar
    • Export Citation
  • 61

    van Vlimmeren L, , van der Graaf Y, , Boere-Boonekamp M, , L'Hoir M, , Helders P, & Englebert R: Risk factors for deformational plagiocephaly at birth and at 7 weeks of age: a prospective cohort study. Pediatrics 119:408418, 2008

    • Search Google Scholar
    • Export Citation
  • 62

    Vles J, , Colla C, , Weber J, , Beuls E, , Wilmink J, & Kingma H: Helmet versus nonhelmet treatment in nonsynostotic positional posterior plagiocephaly. J Craniofac Surg 11:572574, 2000

    • Search Google Scholar
    • Export Citation
  • 63

    World Health Organization Multicentre Growth Reference Study Group: Reliability of anthropometric measurements in the WHO Multicentre Growth Reference Study. Acta Paediatr Suppl 450:3846, 2006

    • Search Google Scholar
    • Export Citation
  • 64

    Zonenshayn M, , Kronberg E, & Souweidane M: Cranial index of symmetry: an objective semiautomated measure of plagiocephaly. J Neurosurg 100:5 Suppl 537540, 2004

    • Search Google Scholar
    • Export Citation

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