Babies with position-related head deformities need specialist evaluation and conservative treatment

Editor calls for ‘new directions’ in deformational plagiocephaly research.

In the two decades since the start of Back to Sleep campaign, doctors and surgeons have seen a surge in the number of infants with position-related head deformities called deformational (or positional) plagiocephaly.

Wolters Kluwer March 03, 2011

Amid often-conflicting recommendations, there’s still a lack of solid scientific data to guide diagnosis and treatment of this problem, according to a special topic section of the Journal of Craniofacial Surgery. The journal is published by Lippincott Williams & Wilkins, a part of Wolters Kluwer Health.

The special issue presents a series of articles and editorials by noted experts, highlighting the need for specialist evaluation and conservative management of infants with deformational plagiocephaly (DP). Editor-in-Chief Mutaz B. Habal, MD, FRCSC, believes the time has come for definitive studies to resolve unanswered questions about infant sleep position, sudden infant death syndrome (SIDS), and position-related skull deformities.

Deformational Plagiocephaly: Defining the Problem

The Back to Sleep^® campaign, initiated in 1992, is widely credited with reducing the rate of SIDS. However, placing infants on their backs to sleep can have the unintended consequence of causing flattening of the skull. If the infant sleeps on the same spot every day, the rapidly growing skull tends to flatten at that spot, becoming deformed and uneven over time.

In a two-part review,^[1,2] Dr. Gary F. Rogers of Children’s National Medical Center in Washington, D.C., outlines the causes, diagnosis, and treatment of DP. According to Dr. Rogers, flattening occurs when cranial growth is redirected by an external force, such as a bed. This is most likely to occur in infants who have limited head mobility related to congenital muscular torticollis, prematurity, or developmental delay. The association between DP and developmental delay has been widely publicized and is a source of great parental concern. However, it is commonly accepted that it is developmental delay that leads to DP, rather than the other way around.

Mild flattening may lend to no treatment or simple repositioning, while more severe cases may benefit from the use of a helmet orthotic to gently redirect the growing cranium into a more normal shape. While these devices are widely used, the effectiveness of this treatment is hotly debated by experts.

Dr. Rogers’ review contrasts the clinical features of deformational cranial flattening with those of other causes of abnormal skull growth—especially conditions called synostoses, in which one or more of the sutures (“soft spots”) of the infant’s head close prematurely. Infants with synostoses require highly specialized surgery and multidisciplinary treatments to prevent serious complications.^[5]

Is Surgery Ever Appropriate?

Unfortunately, many infants with DP are managed without such expert evaluation, which may lead to treatment that is ineffective or unnecessary. The special topic section includes editorials providing expert viewpoints on the evaluation and treatment of DP. While the authors have differing perspectives, all agree that surgery should only be considered in the most severe cases—if at all.

Drs. Wojciech Dec and Stephen M. Warren of New York University Medical Center write, “Growth of the brain tends to restore symmetry of the [skull] when the compressive forces are eliminated.” ^[3] They emphasize the role of head repositioning and helmet therapy, concluding that, “Surgery does not play a role in the treatment of DP.”

Dr. Benjamin Levi of Stanford University and colleagues highlight the need for evaluation by a specialist who can recognize the often-subtle differences between different causes of infant skull deformity.^[4] Although the authors believe that repositioning or helmet therapy is generally effective, they note that the absence of formal studies evaluating the results of treatment—especially surgery. They write, “Children should undergo a thorough physical and radiographic examination by specialists before being subjected to any surgical intervention.

In his editorial, Dr. Habal calls for “new directions of thought” related to “the emergent disease or syndrome” of DP.^[6] He raises special concerns about the lack of unbiased research regarding the outcomes of treatment for DP—as well as the true relationship between supine positioning as called for in the “Back to Sleep Campaign” and SIDS.

Dr. Habal also questions the rapid growth of unproven helmet therapies, noting that “the burgeoning helmet industry has no control in sight.” He reiterates the call for expert, specialist evaluation of infants with possible DP—and urges carefully designed scientific research to definitive research studies to settle the 20-year debate over sleep position, SIDS, and DP.

Source Wolters Kluwer

References

1. Deformational plagiocephaly, brachycephaly, and scaphocephaly. Part I: terminology, diagnosis, and etiopathogenesis, Rogers GF. J Craniofac Surg. 2011 Jan;22(1):9-16. doi: 10.1097/SCS.0b013e3181f6c313. Review.
2. Deformational plagiocephaly, brachycephaly, and scaphocephaly. Part II: prevention and treatment, Rogers GF. J Craniofac Surg. 2011 Jan;22(1):17-23. doi: 10.1097/SCS.0b013e3181f6c342. Review.
3. Current concepts in deformational plagiocephaly, Dec W, Warren SM. J Craniofac Surg. 2011 Jan;22(1):6-8. doi: 10.1097/SCS.0b013e3182074e04. No abstract available.
4. Deformational plagiocephaly: a look into the future, Levi B, Wan DC, Longaker MT, Habal MB. J Craniofac Surg. 2011 Jan;22(1):3-5. doi: 10.1097/SCS.0b013e3181fb7ee5. No abstract available.
5. Severe deformational plagiocephaly: long-term results of surgical treatment, Rogers GF. J Craniofac Surg. 2011 Jan;22(1):30-2. doi: 10.1097/SCS.0b013e3181fb8919. No abstract available.
6. Skull deformities at a crossroads: the need for new directions, Habal MB. J Craniofac Surg. 2011 Jan;22(1):1-2. doi: 10.1097/SCS.0b013e318200dcb8. No abstract available.

Further reading

Treatment of Deformational Plagiocephaly With Physiotherapy, Di Chiara A, La Rosa E, Ramieri V, Vellone V, Cascone P. J Craniofac Surg. 2019 Jun 20. doi: 10.1097/SCS.0000000000005665. [Epub ahead of print]

Head Shape Retention Following Helmet Therapy for Deformational Plagiocephaly, Naidoo SD, Skolnick GB, Galli AD Jr, Patel KB. J Craniofac Surg. 2019 May 21. doi: 10.1097/SCS.0000000000005618. [Epub ahead of print]

Factors influencing outcomes of the treatment of positional plagiocephaly in infants: a 7-year experience, Lam S, Pan IW, Strickland BA, Hadley C, Daniels B, Brookshier J, Luerssen TG. J Neurosurg Pediatr. 2017 Mar;19(3):273-281. doi: 10.3171/2016.9.PEDS16275. Epub 2017 Jan 13.

The Role of Age and Initial Deformation on Final Cranial Asymmetry in Infants with Plagiocephaly Treated with Helmet Therapy, Mackel CE, Bonnar M, Keeny H, Lipa BM, Hwang SW. Pediatr Neurosurg. 2017;52(5):318-322. doi: 10.1159/000479326. Epub 2017 Aug 30.

The course of positional cranial deformation from 3 to 12 months of age and associated risk factors: a follow-up with 3D imaging, Aarnivala H, Vuollo V, Harila V, Heikkinen T, Pirttiniemi P, Holmström L, Valkama AM. Eur J Pediatr. 2016 Dec;175(12):1893-1903. Epub 2016 Sep 13.

Effectiveness of Helmet Cranial Remodeling in Older Infants with Positional Plagiocephaly, Kim HY, Chung YK, Kim YO. Arch Craniofac Surg. 2014 Aug;15(2):47-52. doi: 10.7181/acfs.2014.15.2.47. Epub 2014 Aug 14. Full text

Correction of deformational plagiocephaly in early infancy using the plagio cradle orthotic, Seruya M, Oh AK, Sauerhammer TM, Taylor JH, Rogers GF. J Craniofac Surg. 2013 Mar;24(2):376-9. doi: 10.1097/SCS.0b013e31828010d1.

Helmet treatment of deformational plagiocephaly: the relationship between age at initiation and rate of correction, Seruya M, Oh AK, Taylor JH, Sauerhammer TM, Rogers GF. Plast Reconstr Surg. 2013 Jan;131(1):55e-61e. doi: 10.1097/PRS.0b013e3182729f11.

Helmets and synostosis, Proctor MR, Rogers GF. J Neurosurg Pediatr. 2012 Jun;9(6):680-1; author reply 681-2. doi: 10.3171/2011.10.PEDS11417. No abstract available. Comment on Effect of molding helmet on head shape in nonsurgically treated sagittal craniosynostosis, Sood S, Rozzelle A, Shaqiri B, Sood N, Ham SD. J Neurosurg Pediatr. 2011 Jun;7(6):627-32. doi: 10.3171/2011.4.PEDS116.

About The Journal of Craniofacial Surgery

The Journal of Craniofacial Surgery serves as a forum of communication for all those involved in craniofacial and maxillofacial surgery. Coverage ranges from practical aspects of craniofacial surgery to the basic science that underlies surgical practice. Affiliates include 14 major specialty societies around the world, including The American Association of Pediatric Plastic Surgeons, The American Academy of Pediatrics Section of Pediatric Plastic Surgery, The American Society of Craniofacial Surgeons, The American Society of Maxillofacial Surgeons, The Argentine Society of Plastic Surgery Section of Pediatric Plastic Surgery, The Asian Pacific Craniofacial Association, The Association of Military Plastic Surgeons of the U.S., The Brazilian Society of Craniofacial Surgeons, The European Society of Craniofacial Surgery, The International Society of Craniofacial Surgery, The Japanese Society of Craniofacial Surgery, The Korean Society of Craniofacial Surgery, The Thai Cleft and Craniofacial Association, and The World Craniofacial Foundation

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