positional plagiocephaly the shape of affairs november 21, 2009 patricia mortenson dr. p. steinbok...
TRANSCRIPT
Positional PlagiocephalyThe Shape of Affairs
November 21, 2009
Patricia MortensonDr. P. SteinbokAlan Keith
Agenda (Approximate)
1:00- 1:15 Definition, incidence, risk factors 1:15- 1:45 Synostosis differential (Dr. Steinbok)
1:45 - 2:30 Assessment, treatment, outcomes,
sequelae 15 minute stretch break 2:45 - 3:15 Head banding (Alan Keith)
3:15 - 3:30 Clinical pathways, future, resources 3:30 - 4:00 Questions & problem solving
OBJECTIVES
1. Define positional plagiocephaly & risk factors
2. Be aware of differential diagnoses
3. Learn assessment techniques
4. Understand treatment guidelines
5. Describe outcomes & sequelae
6. Know how and when to make appropriate referrals in BC
PLAGIOCEPHALY?
“oblique head” Causes
– Deformational forces on moldable skull– Nature of the infant skull– Uterine & post-natal positioning– Gravitational forces– Correlation with torticollis
INCIDENCE
More cases with Back to Sleep(Persing et al., 2003)
At birth– 13% in singletons – Flat spots in 56% of twins (Peitsch et al., 2002)
– 61% asymmetry of the head; 16% torticollis (Stelleagen et al., 2008)
Natural History
Followed 200 infants recruited at birth Looked at plagiocephaly/brachycephaly:
– 16% at 6 weeks– 19.7% at 4 months – 6.8% at 12 months – 3.3% at 24 months (Hutchison et al, 2004)
RISK FACTORS
Boy First born Multiple birth Prematurity Intrauterine constraint Torticollis Developmental delay Macrocephaly
Caregiving Factors
Bottle feeding Tummy time < 3X/day Tummy time < 5 min/day Positioning in crib
(van Vlimmeren et al., 2007;
Hutchinson et al., 2003; Losee et al., 2007)
Plagiocephaly & Torticollis
Variable reported co-relations:
e.g.– From 5 – 67% in Texas wide review of
facilities/cases– Variation in diagnosis of CMT and SCM
imbalance– Depends on specialty of facility/service
Pivar & Scheuerle, 2006
TYPES
Occipital Positional Plagiocephaly
www.plagiocephaly.org
Unilateral occipital flattening Ear may be forward (Ipsilateral) Forehead and cheek may be forward (Ipsilateral)
Brachycephaly
www.plagiocephaly.org
Bilateral occipital flattening Side of head widened
Positional Scaphocephaly
www.plagiocephaly.org
Long and narrow head More common in premature babies
ASSESSMENT & TREATMENT
HISTORY
Pregnancy, Birth & Neonatal history When did parents first notice Stayed same, gotten better/worse? Torticollis? What strategies have they already tried
HISTORY
Positioning for sleep, feeding, play ? Tummy Time Time spent in car seats, swings etc. Development
CLINICAL ASSESSMENT
View from top, back, sides, front
CLINICAL ASSESSMENT
Describe shape of head
CLINICAL ASSESSMENT
CLINICAL ASSESSMENT
Eye symmetry & shape When in doubt refer to neurosurgery
Clinical Assessment
Check head turning and tilt
If possible, assess in sitting, supine & prone
? HOW TO QUANTIFY
Measurement
Challenges:– 2D measures on 3D
object– Squirmy subjects
Variety of methods:– Visual ratings– Anthropometric
(caliper measures)– Digital photos – CT scan– Laser scanner
Measurement Issues
Issues with– Classification– Reliability– Cost– Radiation & Sedation
(Mortenson & Steinbok, 2006)
Need standardized classification system (McGarry et al., 2008)
For now….
Argenta’s clinical classification
Severity assessment sheets available at: www.cranialtech.com – ? Reliability / validity
Argenta’s Classification
Type I just back of skull Type II adds mal position of I/L ear Type III adds forehead deformity Type IV adds facial deformity Type V adds temporal bossing or C/L
bossingArgenta, 2004
Argenta’s Classification
Moderately reliable for Types I – IV
(flatenning, ear malposition, frontal bossing, facial asymmetry)
but NOT for vertical skull height(Spermon et al, 2008)
? Degree & responsiveness, ? Validity
Measurement - Brachycephaly
Cranial Index Maximum head breadth X 100
Maximum head length
Scaphocephalic – up to 75.9
Brachycephalic – 81 and over
However ? New norms – wider head shapes with supine sleeping (Pomatto, et al., 2006)
Argenta’s Classification
Type I central posterior skull Type II widening of the skull Type III Temporal or vertical skull growth
Argenta, 2004
? Reliability/validity
TREATMENT
TREATMENT - Positioning
Rapid head growth Positioning for
prevention and treatment
Reverse process
SLEEP POSITION
Place in crib so baby looks into room on the “round” side
Place mobile/crib mirror on “round” side Turn head when asleep
SLEEP PRODUCTS
American Academy Position Statement “We recommend that firm flat bedding be used for normal
healthy infants, with sheets and light blankets as needed, but without products to maintain the sleeping position.”
www.cps.ca/english/statements/IP/cps98-01.htm#sleep
POTENTIAL PRODUCTS
Safe T Sleep www.safetsleep.com
Not approved by CPA
Cautious use, Hutchison et al., 2007
POTENTIAL PRODUCTS
Cranial cup
Custom molded “dish” for head to rest in during sleep
Weak evidence that effective in correcting early plagio
(Rogers et al., 2008)
? Safety and approval for use
UPRIGHT
Use of carriers Hip belts & wide
straps
Ergo carrier
Baby Trecker
PLAY POSITION
Awake & up Tummy timeSupported sittingSide lying for play
TUMMY TIME
Start with short but FREQUENT times
Options include:– On chest– Over legs– Supported on Floor
TUMMY TIME TEACHING
BE: Encouraging Realistic Demonstrate on
baby OR doll
BUMBO
•Not all babies tolerate
•never use on an elevated surface•supervise•www.bumbosafety.com
SIDE LYING
On Round side Best for pre-rollers
Rolled blankets “Sleep” positioning devices
FEEDING POSITION
Bottle feed from “round” side
Feed from “round” side in highchair
BABY EQUIPMENT
Car seat stays in car Stroller 101 Limit Swing Use Good equipment
IMPORTANT FACTORS
Multiple options for caregivers Realistic Demonstration as needed
Address any developmental factors
TREATMENT - Orthotic Headband
Indications– Moderate/severe– Face involved– Positioning not working
How it works Wear
– 23 hours/day for months
Limitations– Cost– Commitment– Hot weather
TREATMENT – Other issues
Torticollis – need to treat– Positioning not as effective
(Losee et al., 2007)
Motor & Developmental delays
Parental guilt
OUTCOMES & SEQUELAE
OUTCOMES
Natural improvement(Hutchison et al., 2004)
Conflicting evidence – 3 systematic reviews– Positioning OR headband > than leaving be– Positioning = headband but takes longer– Helmet > positioning (most studies)
(Bialocerkowski et al., 2005; McGarry, 2008; Xia et al., 2008)
Controversies
Limitations in studies:
1. No standard measures, poor reliability & validity
2. No Randomization
3. Observer and intervention biases– Observers not blinded – More severe cases selected to head band groups
Intensive Intervention
RCT van Vlimmeren, et al., 2008
380 neonates at 7 wks → 68 had positional preference
65 Randomized to 2 groups:– Control → pamphlet only– Intervention → 8 PT sessions for positioning & development
Intervention group → severe plagio reduced by 46% (6 mos) & 57% (12 mos)
At 12 months: No differences in motor development No positional preferences either group
Head banding – long term f/u
Changes post head band are stable at 5 years post treatment
(Lee et al., 2008)
What to do in cases of poor evidence?
What is the goal?
Potential benefits Potential harm
Uncertainty about estimates of these
Regret with a wrong decision
Improved quality of life Improved cosmetics Cost and time High degree of
uncertainty ? Likely low
Phelps, 2008
OUTCOMES
Age of identification & treatment is important
Early identification & treatment = better results (Losee et al., 2007; Persing et al., 2003;
McGarry et al., 2008))
> 12 months – little improvement
EMERGING CONSENSUS?
Infants < 5-6 months → positioning
Infants > 6 months → headband(if no improvement and facial involvement)
Infants > 12 months →limited efficacy
(Losee & Mason, 2005; Graham et al., 2005; McGarry et al., 2008; Xia et al., 2008)
SEQUELAE
Not well studied Weak evidence
Many claims unsubstantiated:– Migraines– Vision problems
Sequelae
Bonding– Infants with molding less cute (Budrea, 1989)
Hearing & Vision– No strabismus (Gupta et al., 2003)– ↓Auditory responses (Balan et al., 2002)
Dental– At 5 yrs, ? Occlusal deformities that may impact orthodontic
planning – not formally studied (Lee et al., 2008)
SEQUELAE - Development
Different distribution of Bayley II scores than norms (Kordestani et al., 2006; Panchal et al., 2001)
– Mental → 90% normal; 0 accelerated; 7% mild
delay; 3% severe delay– Motor → 74% normal; 0 accelerated; 19% mild
delay; 7% severe delay– Other confounding variables – Overstate delay - ? Significant mental delay (yet %
delays within standardized norms)
SEQUELAE - Development
↑Special needs at school (39.7%) (Habal et al., 2003)
More likely to have altered tone compared to control group– No sig. difference in development (Ages & Stages)
(Fowler et al., 2008)
Anthropological evidence - head deformation does not lead to cognitive impairment
(Lekovic et al., 2007)
Development Factors
Delay is a risk factor for PP Children sleeping supine have slower motor development Most children with PP have Normal develop. ? PP a risk factor for delay VS children with delays at ↑ risk of PP
Co relation NOT Cause/effect
PRONE DEVELOPMENT
Systematic review by Pin et al., 2007:
Time in prone correlated to earlier motor milestones - BUT effect was transitory- Similar for pre-term infants, but only 2 studies Baby equipment use does not seem to impact motor ? Movement quality differences ? Impact of lower SES &
infant position on development
LONG TERM SEQUELAE
Not well studied At 5+ years:
– Questionnaires completed by 65 families (278 eligible)
– Residual asymmetry noted by parents in 58%; 21% concerned
– 2 felt to be “very abnormal”; 25 “mildly abnormal”
(Steinbok et al., 2007)
LONG TERM SEQUELAE
18 had used headbands – 14 felt had helped “quite a bit” – Little difference in outcome, but initial bias for who
had been referred for bands
7.7% of children had commented about their head shape
4.6% teased occasionally
LONG TERM SEQUELAE
14% received special assistance in school (BC average is 10.2%)
At initial diagnosis 8% had comorbid diagnoses consistent with delay; 5% had risk factors
Overall reassurance for parents
LONG TERM
Govaert et al., 2008
QOL in post helmet group at preschool age by questionnaire (47% response rate)
No differences in QOL compared to normal group 44/46 parents reported would do helmetting again Weak study
PARENTAL CONCERN
Awareness vs. Information overload fueling consumer drive
TV, newspaper and magazine stories Parent support networks, chat groups
– www.cappskids.org
Commercial products
WHAT WE ARE DOING IN BC
BCCH PROGRAM
4 years ago reaching “critical level” of referrals to neurosurgery
Impact on wait times for critical neurosurgical consults & infants with PP
Limited resources
BCCH PROGRAM
OT Plagiocephaly Clinic
Parent education group with individual assessment
Concurrent with Torticollis & Neurosurgery clinics
4 new patients/wk, 2 follow-ups
BCCH PROGRAM
Parent Satisfaction & waitlists tracked over first year of program:
Parents reported:– feeling comfortable in the group setting – meeting other families was helpful – having all of their questions answered – positive experience
Wait times for infants with PP decreased from 4 to <1 months.
BCCH PROGRAM
Small program (0.1 FTE) Impact of over referrals
– No need to refer mild cases
Other Health Regions
Families outside lower mainland not well served
Often sent down inappropriately or too late
Opportunities for collaboration & regional clinics
WITHIN BC - Headbands
Valley Orthocare Scanner?
No MSP coverage for headbands– Pharmacare– Ministry– Extended Health Plans
WHAT TO DO - Prevention
Back to sleep, tummy for play Early parental awareness
Evaluation of head shape & care giving routines at well baby visits
Early identification and treatment = better results … but don’t stress parents
WHAT TO DO - Plagiocephaly
< 5 months – reposition and monitor
5 + months – If positioning not working– Facial / ear involvement– Moderate to severe
→ consider headband
→ can refer to BCCH OT dept
(need physician referral)
WHAT TO DO - Brachycephaly
More difficult to treat– Can try if severe, treat early
Look at family pattern Flatter & wider may be the new norm
(Pomatto et al., 2006)
TAKE HOME MESSAGES
PREVENTION Reassurance for mild cases
– Monitor, but usually no need for further referral Early Identification & treatment for moderate
to severe cases
Opportunity for collaboration for “Closer to home” services
RESOURCES
Clinician’s Guide available Coming - Caregivers’ Guide
Reference list
Websites with cautionwww.cheo.on.cawww.sickkids.ca – search plagiocephalywww.plagiocephaly.orgwww.cranialtech.comwww.cappskids.org
Comments? Questions?