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Positional Cranial Deformation: Etiology, Natural History, Prevention, Treatment and Sequelae

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A special issue of Journal of Clinical Medicine (ISSN 2077-0383). This special issue belongs to the section "Orthopedics".

Deadline for manuscript submissions: closed (31 December 2019) | Viewed by 41491

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Dr. Kevin M. Kelly

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Department of Anthropology, University of Iowa, 114 Macbride Hall, Iowa City, IA 52242, USA
Interests: biological anthropology; medical anthropology; total worker health; environmental health; occupational health; population health; mixed methods
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Dear Colleagues,

The highly successful 1992 American Academy of Pediatrics recommendation to have healthy infants sleep supine was followed by an increase in the prevalence of nonsynostotic occipital deformations (plagiocephaly), as evidenced by a notable rise in the number of infants being referred to craniofacial and neurosurgical clinics for surgical correction. The “epidemic” spawned a debate around the diagnosis and management of the condition that has not subsided. In 1998, the discussion was further complicated by the United States Food and Drug Administration’s decision to classify cranial orthoses as Class II devices. In 2014, the discourse was inflamed by a now highly criticized clinical trial that, for the first time, failed to see improvements following orthotic treatment. Orthotic correction of positional cranial deformation has long been the standard of care. Nevertheless, the necessity for treatment as well as the management and consequences of the condition continue to be debated. A range of issues remain unresolved—many familiar to those around in the 1990s. These include questions about the etiology and natural history of the condition, the need for standardization of terms, measurement and treatment guidelines, the cost-effectiveness of various treatment modalities, as well as the functional, development, and psychosocial consequences of condition. The objective of this Special Issue to address these issues in order to provide better-informed decisions about prevention and treatment.

Dr. Kevin M. Kelly
Guest Editor

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Keywords

Plagiocephaly
Brachycephaly
Cranial flattening
Flat head syndrome
Risk factors
Cephalometry
Orthotic devices
Treatment outcomes
Development
Motor skills

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Published Papers (7 papers)

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Research

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14 pages, 1425 KiB

Open AccessArticle

Significant Factors in Cranial Remolding Orthotic Treatment of Asymmetrical Brachycephaly

by Tiffany Graham, Kelly Millay, Jijia Wang, Beverley Adams-Huet, Elizabeth O’Briant, Madison Oldham and Shacoya Smith

J. Clin. Med. 2020, 9(4), 1027; https://doi.org/10.3390/jcm9041027 - 5 Apr 2020

Cited by 12 | Viewed by 5188

Abstract

This retrospective chart review focuses on determining the most effective time to begin cranial remolding orthosis (CRO) treatment for infants with asymmetrical brachycephaly. Subjects with asymmetrical brachycephaly started CRO treatment between 3 and 18 months of age. These infants had a cranial vault asymmetry index (CVAI) ≥ 3.5 and a cranial index (CI) ≥ 90. Subjects were excluded if they had any comorbidities affecting growth, dropped out of treatment, were lost to follow-up, or were noncompliant. Factors which were found to statistically influence treatment outcomes were subject initial age, initial CVAI, and initial CI. Overall, younger subjects were more likely to achieve a corrected head shape. The presence of prematurity or torticollis had statistically nonsignificant effects on the success of treatment. Initial CI was found to be a stronger predictor than initial CVAI as to which subjects achieved correction. The less severe the starting CI, the more likely the subject was to achieve full correction. The clinical understanding is that it requires more cranial growth to “round out” a full posterior skull flattening than an asymmetry. Based on the study results, infants with asymmetrical brachycephaly should be treated as early as possible to increase chances of achieving full correction of the deformity. Full article

(This article belongs to the Special Issue Positional Cranial Deformation: Etiology, Natural History, Prevention, Treatment and Sequelae)

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15 pages, 1354 KiB

Open AccessArticle

Craniofacial Asymmetry from One to Three Years of Age: A Prospective Cohort Study with 3D Imaging

by Anniina M. Launonen, Ville Vuollo, Henri Aarnivala, Tuomo Heikkinen, Pertti Pirttiniemi, A. Marita Valkama and Virpi Harila

J. Clin. Med. 2020, 9(1), 70; https://doi.org/10.3390/jcm9010070 - 27 Dec 2019

Cited by 14 | Viewed by 5461

Abstract

Deformational plagiocephaly (DP) is considered a risk factor for facial asymmetry. This cohort-based, prospective, follow-up study used three-dimensional (3D) stereophotogrammetry to assess the development of facial asymmetry in a normal birth cohort and to investigate the impact of DP on facial asymmetry for the age range of one to three years. The study sample consisted of 75 children: 35 girls (47%) and 40 (53%) boys recruited from Oulu University Hospital. A total of 23 (31%) subjects had a history of DP in infancy. 3D facial images were obtained at the mean (SD) age of 1.01 (0.04) year old at T1 and 3.02 (0.14) years old at T2. To determine facial asymmetry, both landmark-based and surface-based facial symmetry methods were used. As measured with the surface-based methods, upper facial symmetry improved from T1 to T2 (p < 0.05). As measured with the landmark-based methods, facial symmetry improved on the upper and lower jaw from T1 to T2 (p < 0.05). The asymmetric effect of DP on the upper parts of the face tends to correct spontaneously during growth. Results indicate that previous DP does not seem to transfer to facial or occlusal asymmetry at the age of three years old. Full article

(This article belongs to the Special Issue Positional Cranial Deformation: Etiology, Natural History, Prevention, Treatment and Sequelae)

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5 pages, 210 KiB

Open AccessCommunication

Plagiocephaly after Neonatal Developmental Dysplasia of the Hip at School Age

by A Marita Valkama, Henri I Aarnivala, Koshi Sato, Virpi Harila, Tuomo Heikkinen and Pertti Pirttiniemi

J. Clin. Med. 2020, 9(1), 21; https://doi.org/10.3390/jcm9010021 - 19 Dec 2019

Cited by 5 | Viewed by 2721

Abstract

Developmental dysplasia of the hip (DDH) may require early abduction treatment with infants sleeping on their back for the first few months of life. As sleeping on back is known to cause deformational plagiocephaly, we assessed school age children treated for dislocation or subluxation of the hip-joint in infancy. Plagiocephaly was analyzed by using cephalic index (CI) and oblique cranial length ratio (OCLR) as anthropometric measurements from 2D digital vertex view photographs. Six of the 58 (10.3%) DDH children and only one of the 62 (1.6%) control children had plagiocephaly (p = 0.041). Furthermore, cross bite was found in 14 (24.1%) of the DDH children and in 7 (10.3%) of the control children. Developmental dysplasia of the hip in infancy was associated with cranial asymmetries and malocclusions at school age. Preventive measures should be implemented. Full article

(This article belongs to the Special Issue Positional Cranial Deformation: Etiology, Natural History, Prevention, Treatment and Sequelae)

10 pages, 1767 KiB

Open AccessArticle

The Effects of Helmet Therapy Relative to the Size of the Anterior Fontanelle in Nonsynostotic Plagiocephaly: A Retrospective Study

by Do Gon Kim, Joon Seok Lee, Jeong Woo Lee, Jung Dug Yang, Ho Yun Chung, Byung Chae Cho and Kang Young Choi

J. Clin. Med. 2019, 8(11), 1977; https://doi.org/10.3390/jcm8111977 - 14 Nov 2019

Cited by 9 | Viewed by 4089

Abstract

Helmet therapy is an important nonsurgical approach for patients with nonsynostotic plagiocephaly, but its effectiveness may depend on certain anatomical features. We retrospectively examined the effects of helmet therapy according to the size of the anterior fontanelle. Two hundred patients with nonsynostotic plagiocephaly who underwent helmet therapy between 2016 and 2018 were included. Data regarding age at treatment onset and treatment duration were collected. Patients were divided into two groups depending on the age at treatment initiation: the 12–23 weeks group and the >23 weeks group. Patients were also divided based on the anterior fontanelle size to analyze the effects of helmet therapy according to the severity of plagiocephaly in each group as the change in the cranial vault asymmetry index (CVAI). Therapeutic effects were evaluated using the cranial vault asymmetry (CVA), CVAI, anterior symmetry ratio, posterior symmetry ratio (PSR), and overall symmetry ratio at baseline and treatment completion. Treatment initiation at age 12–23 weeks resulted in better effects than that after age 24 weeks. There were no sex-dependent differences in therapeutic effects. Greater changes in the CVA, CVAI, and PSR were associated with larger anterior fontanelles. Therefore, the anterior fontanelle size could be a prognostic factor for estimating helmet therapy outcomes. Full article

(This article belongs to the Special Issue Positional Cranial Deformation: Etiology, Natural History, Prevention, Treatment and Sequelae)

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12 pages, 1163 KiB

Open AccessArticle

A 3D Follow-Up Study of Cranial Asymmetry from Early Infancy to Toddler Age after Preterm versus Term Birth

by Anniina M. Launonen, Henri Aarnivala, Panagiotis Kyteas, Ville Vuollo, Tuomo Heikkinen, Chung H. Kau, Pertti Pirttiniemi, Virpi Harila and A. Marita Valkama

J. Clin. Med. 2019, 8(10), 1665; https://doi.org/10.3390/jcm8101665 - 11 Oct 2019

Cited by 8 | Viewed by 3902

Abstract

Preterm infants are at higher risk for both symmetrical and asymmetrical head molding. This study involved 3D stereophotogrammetry to assess the cranial growth, molding, and incidence of deformational plagiocephaly (DP) in preterm children compared to term born children. Thirty-four preterm infants and 34 term born controls were enrolled in this study from Oulu University Hospital, Finland. Three-dimensional head images were obtained at the age of 2–4 months (T1), 5–7 months (T2), 11–13 months (T3), and 2.5–3 years (T4) from the term equivalent age (TEA). There was no statistically significant difference in oblique cranial length ratio (OCLR), cephalic index (CI), or weighted asymmetry score (wAS) between the two groups. Occipital flattening, defined by flatness score (FS) was statistically significantly greater in the preterm group than in the term group at T1–T4 (p < 0.05). In both groups, OCLR improved gradually over time. There were no instances, in either group, of severe DP and no moderate DP after T2. Results indicate that DP affects preterm and full-term children almost equally during the first three years of life, and cranial asymmetry resolves at a similar rate in both preterm and term groups after three months of corrected age. Preterm infants present with more occipital flattening than full-term children. Full article

(This article belongs to the Special Issue Positional Cranial Deformation: Etiology, Natural History, Prevention, Treatment and Sequelae)

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10 pages, 755 KiB

Open AccessArticle

Effects of Initial Age and Severity on Cranial Remolding Orthotic Treatment for Infants with Deformational Plagiocephaly

by Tiffany Graham, Beverley Adams-Huet, Nicole Gilbert, Kirsten Witthoff, Terran Gregory and Mary Walsh

J. Clin. Med. 2019, 8(8), 1097; https://doi.org/10.3390/jcm8081097 - 24 Jul 2019

Cited by 25 | Viewed by 5825

Abstract

The aim of this study is to review the effects of an infant’s presenting age and severity of deformation on cranial remolding orthotic (CRO) treatment outcomes for patients with deformational plagiocephaly. This study is a retrospective chart review of 499 infants with non-synostotic plagiocephaly who completed CRO treatment. Data collected included age at start of treatment, head shape measurements before and after treatment, total months of CRO treatment, and other factors such as presence/absence of prematurity. The infants were divided into subgroups according to age and severity at initiation of treatment and data for subgroups was analyzed to track the change in head shape over the course of treatment, review overall treatment duration, and discuss the rate of change of cranial deformation. Overall, treatment times tended to statistically increase with increasing initial severity and age. Posttreatment asymmetry measurements statistically trended to greater residual deformation in infants who began treatment in the older or more severe subcategories. This indicates that younger and less severe infants have shorter treatment durations and less residual cranial deformation after CRO treatment. Therefore, clinical consideration may need to be taken to treat infants at younger ages or prior to progression of the cranial deformity. Full article

(This article belongs to the Special Issue Positional Cranial Deformation: Etiology, Natural History, Prevention, Treatment and Sequelae)

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Review

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15 pages, 6744 KiB

Open AccessReview

Nonsynostotic Plagiocephaly: Prevention Strategies in Child Health Care

by Freda Lennartsson

J. Clin. Med. 2020, 9(12), 3946; https://doi.org/10.3390/jcm9123946 - 5 Dec 2020

Cited by 2 | Viewed by 3046

Abstract

The dissertation, comprising a clinical intervention and three supporting studies, aimed to assess if it is possible to prevent nonsynostotic plagiocephaly while promoting safe infant sleeping practices. Five individuals were trained to assess cranial asymmetry and then reliability-tested; the interpreted results indicate substantial strength of rater-agreement. Intervention participants were allocated to group. Only intervention group nurses participated in the continuing education on plagiocephaly developed for nurses. A survey compared information intervention and control group parents received from nurses; intervention group parents were significantly more aware of recommendations than the controls. Nurse education was evaluated by asking intervention and control group nurses and parents two open-ended questions; the intervention group reported new re-positioning strategies. The effect of the intervention on cranial shape was evaluated by assessing asymmetry at 2, 4, and 12 months (176 intervention group; 92 controls). It was nine times more common that cranial asymmetry at two months reversed by four months when parents were aware of written recommendations from their nurse (OR = 9.09 [0.02; 0.48], p = 0.004) when adjusted for group. An infant’s risk of asymmetry persisting until 12 months was significantly reduced in the intervention group (RR = 0.35 [0.13; 0.94], p = 0.03). Preventing brachycephaly was difficult. Conclusions: the assessors were considered reliable; educating nurses promoted the integration of new recommendations in practice; the intervention was associated with early reversal of nonsynostotic plagiocephaly. Full article

(This article belongs to the Special Issue Positional Cranial Deformation: Etiology, Natural History, Prevention, Treatment and Sequelae)

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