Identify infants with positional preference early and consider referral to pediatric physical therapy at 7 or 8 weeks to prevent severe deformational plagiocephaly (DP). Stength of recommendation: B: Based on a single well-done randomized controlled trial (RCT)

Ewigman, Bernard

Hickner, John

Mendoza, Michael D.

Vargish, Lisa

University of Missouri: MOspace

	 vol	58,	No	8	/	August	2009	 Ewww.jfponline.comPURLs®Priority Updates from the Research Literature from the Family Physicians Inquiries NetworkIllustratIve caseDuring	a	 routine	 checkup	of	 a	 2-month-old	boy,	you	notice	that	the	left	side	of	his	head	is	slightly	flatter	 than	 the	 right	and	his	 fore-head	protrudes	forward	more	on	the	left	than	the	right.	His	birth	history	and	development	are	normal.	You	wonder	if	the	asymmetry	will	resolve	as	the	infant	grows	older	or	whether	you	should	suggest	immediate	treatment.The American Academy of Pediat-rics recommends putting babies to sleep on their backs to reduce the risk of sudden infant death syndrome. As more parents have followed this recommendation, the incidence of posi-tional preference and DP has increased, presumably because external pressure distorts the malleable infant cranium. Prenatal and intrapartum factors also can cause DP, but sleeping on the back likely accounts for the recent increase.2-4 z  Not just a cosmetic issue Although many clinicians consider skull deformities to be purely cosmetic,5 pla-giocephaly is associated with auditory processing disorders, mandibular asym-metry, and visual field defects. Head deformities resulting from premature fusion of the cranial sutures (craniosyn-ostosis) have been linked to an increased incidence of speech-language, cognitive, behavioral, and neurodevelopmental ab-normalities.6,7 Whether these associations are causal is not yet known.5 Many par-ents believe that unattractive facial fea-tures lead to adverse effects on children, such as teasing and poor self-esteem.5,6 Conservative treatments for posi-tional preference and DP include pa-rental counseling, counter-positioning, simple exercises, and orthotic devices such as helmets.8 Scientific evidence supporting the effectiveness of these ap-proaches is weak. The study we review Identify	infants	with	positional	preference	early	and	consider	referral	to	pediatric	physical	therapy	at	7	or	8	weeks	to	prevent	severe	deformational	plagiocephaly	(DP).1strength	of	recommendation:  B:  Based	on	a	single	well-done	randomized	controlled	trial	(RCt).van	vlimmeren	lA,	van	der	graaf	Y,	Boere-Boonekamp	MM,	et	al.	Effect	of	pediatric	physical	therapy	on	deformational	plagiocephaly	in	children	with	positional	preference:	a	random-ized	controlled	trial.	Arch Pediatr Adolesc Med.	2008;162:712-718.Practice changer Use physical therapy to head off this deformity in infantsConsider	early	Pt	to	prevent	severe	deformational		plagiocephaly.Lisa Vargish, MD, MS,Michael D. Mendoza, MD, MPH, and Bernard  Ewigman, MD, MSPHDepartment of Family Medicine, The University of ChicagoP U R L s  E D i T o R  John Hickner, MD, MSc Department of Family Medicine, Cleveland Clinicfast trackMore babies  sleeping on  their back likely accounts for the recent increase in the incidence of  positional  preference  and DP.PURLs methodologyThis study was selected and evaluated using FPIN’s Priority Updates from the Research Literature (PURL) Surveillance System methodology. The criteria and findings leading to the selection of this study as a PURL can be accessed at www.jfponline.com/purls. OnlIne exclusIveCopyright® Dowd n Health Media  For personal use onlyFor mass reproduction, content licensing and permissions contact Dowden Health Media.fast trackPURLs®E vol	58,	No	8	/	August	2009		the JOurnal Of famIly PractIcein this PURL provides strong evidence of the effectiveness of 1 intervention—physical therapy (PT).study summaryz  Early physical therapy prevents severe DP van Vlimmeren and colleagues con-ducted a prospective RCT compar-ing PT with usual care for preventing DP.1 From a group of 400 infants born consecutively in the Netherlands, they identified 65 with positional prefer-ence at 7 weeks of age and randomized them to PT or a control group. Pediat-ric physical therapists blinded to group allocation evaluated each infant at 6 and 12 months. Babies with congeni-tal muscular torticollis (defined as pref-erential posture of the head and asym-metrical cervical movements caused by a unilateral contracture of the sterno-cleidomastoid muscle), dysmorphisms, or congenital syndromes were excluded. The PT and control groups were comparable at baseline. Parents of infants in the control group received a pamphlet about basic preventive measures, but no additional instructions. Infants in the in-tervention group received standardized pediatric PT from trained therapists who were unaware of the results of the infants’ baseline assessments.  PT consisted of 8 sessions between 7 weeks and 6 months of age. The first 4 sessions were held weekly; subsequent sessions occurred every 2 to 3 weeks. The second through fifth sessions took place at the infant’s home. The intervention included exercis-es to reduce positional preference and stimulate motor development, along with parental counseling about counter-positioning, handling, nursing, and the causes of positional preference. Parents received a pamphlet describing basic measures to prevent DP. The therapists also encouraged earlier and more fre-quent play times in the prone position (“tummy time”). PT was discontinued when the infant no longer demonstrat-ed positional preference while awake or asleep, parents were following advice about handling, and the baby exhibited no signs of motor developmental delay or asymmetries. The primary outcome was severe DP, measured as an oblique diam-eter difference index (ODDI) score of 104% or more—a score representing asymmetry of the skull that is obvi-ously noticeable and therefore consid-ered clinically relevant.9 The secondary outcome measures were symmetry in posture and active movements, motor development, and passive range of mo-tion of the cervical spine.  Intervention reduced dP at 6 and 12 months. By 6 months of age, the num-ber of infants in the intervention group with severe DP had decreased signifi-cantly from 53% to 30%, compared with a decrease from 63% to 56% in the control group (relative risk [RR]=0.54; 95% confidence interval [CI], 0.30-0.98; number needed to treat [NNT]=3.85). At 12 months, the  number of babies in the intervention group with severe DP had decreased further, to 24%, whereas the number in the control group remained unchanged at 56% (RR=0.43; 95% CI, 0.22-0.85; NNT=3.13). secondary outcomes comparable. No major differences in secondary out-comes were noted between the 2 groups. At 6 and 12 months of age, none of the infants had positional preference or dif-ferences in motor development. Passive range of motion of the cervical spine was within normal range and symmetrical in all infants at baseline and at 6 and 12 months. However, at the 6-month evalua-tion, parents of babies in the intervention group demonstrated greater symmetry and less left orientation in nursing, posi-tioning, and handling of the infants.What’s neWz  Early intervention trumps conservative therapies  This is the first RCT of a pediatric PT program to treat infants with position-Beyond cosmetic concerns, DP  is associated  with problems  such as auditory  processing  disorders,  mandibular  asymmetry,  and visual field defects.CoNt INuEDfast trackDeformational plagiocephaly	 vol	58,	No	8	/	August	2009	 Ewww.jfponline.comal preference to prevent severe plagio-cephaly, and the study provides strong evidence to support this practice. The study included healthy infants, much like the ones we encounter in primary care practice. If, as we suspect, many of us have been recommending con-servative therapies, we have reason to consider referral for this increasingly common clinical problem.caveatsz  Study did not focus  on serious deficitsThis study excluded infants with congen-ital muscular torticollis, dysmorphisms, or other congenital syndromes. We need to be aware of these causes of DP, which may warrant additional referrals beyond pediatric PT. In addition, DP should be distinguished from craniosynostosis, which requires referral for surgical evalu-ation and treatment. cosmetic issues vs more serious problems. DP is the most benign of the many causes of head deformities. The outcomes of this trial mainly addressed the cosmetic issue rather than more seri-ous deficits associated with plagiocepha-ly. Nevertheless, we believe that cosmetic considerations are important to parents and children. What’s more, the interven-tion carries no risk of adverse effects and produces notable benefit. We conclude that discussing PT referral with parents is the appropriate practice change to im-plement based on this study.Infant age, length of follow-up. Be-cause this study did not evaluate the im-pact of the intervention on infants older than 7 to 8 weeks, it is not clear whether PT would be as effective if begun later in infancy. The relatively short follow-up (12 months) precludes conclusions about outcomes such as social functioning and school performance.   challenGes tO ImPlementatIOnz  A matter of timeThe incidence of positional prefer-ence has been reported to be as high as 22% at 7 weeks, making it a relatively common problem encountered by fam-ily physicians.7 Most children with posi-tional preference do not develop DP and when they do, it is typically a cosmetic problem. Ruling out torticollis, cranio- synostosis, and other congenital causes is critical. Ascertaining parental preference is a major consideration in the decision to refer for PT. All of this takes time. However, parents are often con-cerned about their baby’s misshapen skull. We think that addressing positional preference is time well spent, especially since we now have evidence that a non-invasive approach—PT—can effectively prevent DP. nacknowledgementsthe	PuRls	surveillance	system	is	supported	in	part	by	grant	Number	ul1RR024999	from	the	National	Center	for	 Research	 Resources,	 a	 Clinical	 translational	 sci-ence	Award	to	 the	university	of	Chicago.	the	content	is	solely	the	responsibility	of	the	authors	and	does	not	necessarily	 represent	 the	official	views	of	 the	National	Center	 for	 Research	 Resources	 or	 the	 National	 Insti-tutes	of	Health.references 	 1.	 	van	 vlimmeren	 lA,	 van	 der	 graaf	 Y,	 Boere-Boonekamp	MM,	et	al.	Effect	of	pediatric	physical	therapy	on	deformational	plagiocephaly	in	children	with	 positional	 preference.	 Arch Pediatr Adolesc Med.	2008;162:712-718.		 2.	 	de	Jonge	gA,	Engelberts	AC,	Koomen-liefting	AJ,	et	al.	Cot	death	and	prone	sleeping	position	in	the	Netherlands.	BMJ.	1989;298:722.	 3.	 	Engelberts	AC,	de	Jonge	gA.	Choice	of	sleeping	position	 for	 infants:	possible	association	with	cot	death.	Arch Dis Child.	1990;65:462-467.	 4.	 	American	Academy	of	Pediatrics	task	Force	on	In-fant	Positioning	and	sIDs.	Positioning	and	sIDs.	Pediatrics.	1992;89:1120-1126.	 5.	 	Balan	P,	Kushnerenko	E,	 sahlin	P,	 et	 al.	 Auditory	ERPs	reveal	brain	dysfunction	 in	 infants	with	pla-giocephaly.	J Craniofac Surg.	2002;13:520-525.	 6.	 	st	John	D,	Mulliken	JB,	Kaban	lB,	et	al.	Anthropo-metric	analysis	of	mandibular	asymmetry	in	infants	with	deformational	posterior	plagiocephaly.	J Oral Maxillofac Surg.	2002;60:873-877.	 7.	 	Hutchison	Bl,	Hutchison	lA,	thompson	JM,	et	al.	Plagiocephaly	 and	 brachycephaly	 in	 the	 first	 two	years	of	life:	a	prospective	cohort	study.	Pediatrics.	2004;114:970-980.	 8.	 	speltz	Ml,	Kapp-simon	KA,	Cunningham	M,	et	al.	single-suture	 craniosynostosis:	 a	 review	 of	 neu-robehavioral	 research	 and	 theory.	 J Pediatr Psy-chol.	2004;29:651-668.	 9.	 	van	vlimmeren	lA,	takken	t,	van	Adrichem	lN,	et	al.	Plagiocephalometry:	a	non-invasive	method	to	quantify	asymmetry	of	the	skull;	a	reliability	study.	Eur J Pediatr.	2006;165:149-157.We think that  addressing  positional  preference is  time well spent. 

Use physical therapy to head off this deformity in infants

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