Does my child have a

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Does my child have a flat head?

• Lloyd Ellis Anna Noisette
• The Royal Childrens Hospital, Melbourne

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Objectives of todays session

• Types of cranial asymmetry
• Identification of torticollis types
• Prevention
• Monitoring change
• RCH model
• Helmet therapy
• Resources/Questions
• Future?

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The Skull
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Craniosynotosis
Fused Suture Name Description
Sagittal Scaphocephaly Boat Skull
Metopic Trigonocephaly Triangular Skull
Unilateral Coronal Plagiocephaly Asymmetric Skull
Bicoronal Brachycephaly Short Skull
Lambdoid Plagiocephaly Asymmetric Skull
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Scaphocephaly
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Scaphocephaly
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Scaphocephaly
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Trigonocephaly
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Does my child have a flat head?
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What causes deformational Plagiocephaly?

• Prolonged pressure the skull in a particular
  position
• SIDS protocols Back to sleep
• Torticollis a tightening of the neck muscles
• Macrocephaly
• Child resistant to tummy time / muscle weakness
• Lack of education of prevention methods
• Utero constraints eg multiple births,
  insufficient pelvis
• The expanding brain applies an externally
  directed force, with the brain capable of extreme
  plastic deformation with no loss of function or
  intellect if volume is not reduced

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Sleeping Position

• 1992 AAP recommended infants sleep supine/side to
  reduce SIDS risk
• Revised 1996 no sidelying sleeping
• Victorian statistics
• 1989 513 SIDs deaths/year
• 2000 140 SIDS deaths/year

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Incidence

• SIDS reduced significantly since inception of
  Back to Sleep campaign (up to 40) (Task Force
  on Sudden Infant Death Syndrome, 2005 Saeed et
  al., 2008 Xia et al., 2008 Losee Mason,
  2005).
• Dramatic increase (10-48) in incidence of
  plagiocephaly since Back to Sleep campaign
  (Saeed et al., 2008 Habal et al., 2004 Persing
  et al., 2003 Xia et al., 2008).
• 13-15 singletons have some flattening
• Right side more common
• 1.3 incidence torticollis
• Deformity persists in 30 at 2 years

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Risk factorsfound repeatedly

• Male
• First born
• Multiple pregnancy
• Prematurity
• Oligohydramnios
• Supine sleeping
• lt 5 mins tummy time/day
• Delayed motor milestones
• Preferred head orientation for sleep at 6 weeks
• Positioning to same side for all bottle feeds

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Decreased Prone Play

• Decreased awareness of the importance of
  supervised tummy time, extended time on back
• WHY?
• Parental fears
• Infant intolerance

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Treatment of Plagiocephaly

• Wait and See!
• If torticollis present, treat with
  physiotherapy/gentle stretching
• Counter positioning
• Changing the forces on the head by altering the
  lying position
• Cranio-reshaping helmet therapy
• Fitting a custom made helmet which is worn for
  23/34 hours a day until improved cosmesis is
  achieved

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Classifications

• Macdonald 1969 gave 3 classifications
• Sternomastoid tumour group (42.7)
• palpable mass present
• Muscular torticollis group (30.6)
• tight SCM but no palpable mass
• Reduced active/passive ROM
• Postural torticollis group (22.1)
• no palpable mass or tightness
• Full active/passive ROM Cheng 2000

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Congenital Muscular Torticollis (CMT)

• CMT usually presenting with unilateral tightness
  of the sternocleidomastoid (SCM) muscle (Luther,
  2002)
• Characterised by lateral flexion to the affected
  side and rotation away from the affected side

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Physiotherapy Rx

• Goals of Physiotherapy
• increase PROM
• increase AROM
• Improving facial and cranial symmetry
• Encourage gross motor development
• Education, Stretching, Counter positioning
  techniques including positions carrying and for
  play

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Counter Positioning

• Parent education
• Active and consistent repositioning of infant
  during play to apply pressure to prominent part
  of the skull
• Use of passive devices to position baby,
  specially designed devices

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Counter positioning

• Positioning, play and carrying techniques to
  encourage movement to neglected side and
  lengthen tight muscles

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Variety of positions for play

• Supervised tummy time whilst the infant is
  awake
• Head shape and motor development are affected by
  sleep and awake positions of infant

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Prevention is the key !
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Key Preventative Strategies

• Early detection of torticollis referral to
  Physiotherapy
• Encourage prone side-lying during supervised
  awake play periods several times per day
• Nightly/weekly alternating head positioning
  during supine sleeping
• Avoid prolonged repetitive positioning (e.g. Car
  seat carriers, buggies, baby swings bouncers.
• Regularly change position of cot in room or
  toys/mobiles around cot.
• Counter positioning / alternating the orientation
  of infant in the cot
• Alternating feeding positions.
• (Saeed et al., 2008 Task Force on Sudden Infant
  Death Syndrome, 2005 Neufeld Birkett, 1999
  Persing et al., 2003 van Vlimmerman et al.,
  2008., Canadian Paediatric Society, 2001).

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Assessment

• History
• Examination
• Severity scoring
• Measurement
• Closure of anterior fontanelle
• Range 4 to 18m

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Clinical Severity Score
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RCH treatment model

• Research into the effectiveness of conservative
  management is just beginning
• 3d Capture
• Counterpositioning initial treatment
• Follow-up 3d review
• Physiotherapy if torticollis present
• Orthotic management for severe cases in older
  infants (from 6/12 old)

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To treat or not to treat?

• Cosmetic condition
• Studies have shown that helmets improve the head
  shape
• No study has been conducted to see if the
  condition self corrects regardless of treatment
• Who should we treat ?
• Last resort when conservative management fails.
  They are not an easy option
• Significant time and resource costs for health
  services and families

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Indications for referral to RCH Deformational
Plagiocephaly Clinic

• Failure of early treatment strategies
• Severe deformity
• Severe torticollis and restriction
• Associated medical conditions
• Prematurity
• Developmental delay

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Helmet Therapy

• Do not affect the growing brain
• Not the easy option!
• They are a significant cost in time and resources
  for families
• For most children they shouldnt be required

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RCH treatment protocol

• To qualify a child must
• Have a deformational score of 6 or greater on
  the assessment sheet or
• Score a 3 in a single deformation change
• Be at least 6 months old
• Have no craniosynostosis
• Helmets do not treat torticollis!

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How does it work?
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Wearing Regime

• Helmet is worn in gradually over 3-7 days (day
  time only), then worn 23/24 for duration of
  treatment
• Review every 4-6 weeks according to growth
• Repeating 3D photos mid treatment and end of
  treatment

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The Finished product
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The process

• 3D photography using 5 point camera
• Use to manufature helmet
• Baseline to see shape improvement

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Helmet Therapy
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Helmet Therapy
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Helmet Therapy
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Helmet Therapy
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Helmet Therapy
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Helmet Therapy
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Helmet Therapy
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Helmet Therapy
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Helmet Therapy
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Positional Therapy
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Positional Therapy
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Positional Therapy
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Positional Therapy
7mths 8.5mths
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Positional Therapy
8mths 9.5 mths 12mths
24mths 5yrs
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Deformational Plagiocephaly - Mild
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Deformational Brachycepahley - Mild
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Deformational Plagiocephaly Moderate / Serve
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Deformational Plagiocephaly Moderate / Serve
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Deformational Plagiocephaly Moderate / Serve
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Deformational Plagiocephaly Moderate / Serve
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RCH - What are we doing?

• Development of brochure poster
• - Back to Sleep Tummy Time to Play
• How to Protect Your Babys Head Shape
• Available from APA
• Plagiocephaly Fact sheet for parents RCH
  website
• Plagiocephaly Clinic

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Future Objectives

• Educational material on positional
• plagiocephaly to

• Raise awareness
• Early recognition
• Early management
• Prevention

Further research required in

• Natural history of plagiocephaly
• Severity rating of plagiocephaly
• Objective outcome measures

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Conclusion

• Early detection of deformational plagiocephaly
  within 6-10wks and positional therapies followed
  there is a greater degree of avoiding helmet
  therapy.

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Acknowledgements

• Sharon Vladusic, Senior Physiotherapist,
  Orthopaedic Department, RCH
• Dr. Susie Gibb, Consultant Paediatrician,
  Department of General Paediatrics, RCH
• Angela Serong, Senior Physiotherapist, RCH

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Questions?
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References

• Canadian Paediatric Society. (2001). CPS
  Statement Update Positional plagiocephaly and
  sleep positioning an update to the joint
  statement on sudden infant death syndrome.
  Paediatr Child Health, 6, 788-789.
• De Ribaupierre S et al. Posterior plagiocephaly
  treated with cranial remodeling orthosis. Swiss
  med Weekly 2007 137 368-72.
• Habal, M.B., Castelano, C., Hemkes, N.,
  Scheuerle, J., Guilford, A. M. (2004). Clinical
  Note In search of causative factors of
  deformational plagiocephaly. The Journal of
  Craniofacial Surgery, 15, 835-841.
• Losee, J.E., Mason, A.C. (2005). Deformational
  plagiocephaly diagnosis, prevention and
  treatment. Clin Plastic Surg, 32, 53-64
•  

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• Neufeld, S., Birkett, S. (1999). Clinical
  Notebook. Positional plagiocephaly a community
  approach to prevention and treatment. Alta RN,
  Jan-Feb, 55, 15-16.
• NHS Quality improvement Evidence note 16 The use
  of cranial orthosis treatment for infant
  deformational plagiocephaly, Scotland, 2007.
• Persing, J., James, H., Swanson, J., Kattwinkel,
  J. (2003). Prevention and management of
  positional skull deformities in infants.
  Pediatrics, 112, 199-202.
• Saeed, N.R., Wall, S.A., Dhariwal, D. K.
  (2008). Management of positional plagiocephaly.
  Arch Dis Child, 93, 82-84.
• Steinbok P et al. Long term outcome of infants
  with positional plagiocephaly. Childs Nervous
  System 2007 23 1275-83.

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• Task Force on Sudden Infant Death Syndrome.
  (2005). The changing concept of sudden infant
  death syndrome diagnostic coding shifts,
  controversies regarding the sleep environment,
  and new variables to consider in reducing risk.
  Pediatrics, 116, 1245-1255.
• Van Vlimmeren LA et al. (2007). Risk Factors for
  Deformational Plagiocephaly at birth and 7 weeks
  of age A prospective cohort study, Pediatrics
  ,119 22006-2012.
• Van Vlimmeren LA et al (2008). Effect of
  Pediatric physical therapy on deformational
  plagiocephaly in children with Positional
  preference. A randomized controlled trial, Arch
  Ped Adol Med ,1628712-718.
• . Xia, JJ et al. (2008). Nonsurgical treatment of
  deformational plagiocephaly, a systematic review.
  Arch Ped Adol Med,162 8 719-20.