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Background: Positional plagiocephaly (PP) is an asymmetric deformation of the skull as a consequence of external forces acting on a normal and pliable skull. The prevalence of PP ranges between 19.6% and 46.6%. Treatment options for PP include repositioning, physical therapy, and helmet orthoses. Consensus regarding the treatment of PP remains elusive due to the condition's imprecise natural history, dissimilar diagnostic strategies, and unreliable data asserting treatments' efficacy. Our aim was to conduct a systematic review of the tools used to diagnose, suggest treatment strategies, and assess outcomes for PP., Methods: We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to query a variety of databases. A total of 444 articles were imported into Covidence, a screening and data extraction tool for conducting systematic reviews., Results: After a series of screenings, 60 articles met inclusion criteria and were reviewed in detail. The information was entered into a data extraction list consisting of 16 variables in the categories of general information, diagnostic strategies, treatment modalities, and treatment outcomes. Most articles reported retrospective case series, which yielded level 4 evidence. Only one article reported the results of a randomized and blinded outcomes assessment trial. Such article yielded level 1 evidence and was rated as high quality for allocation, concealment, and blinding of personnel., Conclusion: The strategies used to diagnose and classify PP are a disparate list of measures most of which have no parallels making it impossible to offer treatment recommendations and generate generalizable knowledge., Competing Interests: Declaration of competing interest The authors have no conflicts of interest to report., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Positional plagiocephaly is a common pediatric pathology that has been considered as a cosmetic condition, but recently its association with neurodevelopmental delay has been explored., Objective: To perform a narrative review updating the findings of a 2017 systematic review on plagiocephaly and neurodevelopment., Methodology: Articles in the MEDLINE, PubMed, Google Scholar, and DeepDyve databases were reviewed, data were extracted from the most relevant studies evaluating their methodological quality. The search terms used were: "plagiocephaly", "positional plagiocephaly", "brachycephaly", "motor skills", "development", "developmental delay", "neurodevelopment", "language acquisition", "psychomotor performance", and "cognition"., Results: The search found 198 articles, of which 14 met the inclusion criteria. A child population aged 4 to 11 months to 8 years was observed. The study highlighted limitations including potential selection bias, use of the same population in several studies, and lack of diagnostic consistency. The results showed a positive association between plagiocephaly and neurodevelopmental delay. The studies of higher methodological quality identified delays in different developmental stages (7, 18, and 36 months, and school-age) and dimensions (motor skills, cognition, behavior, and language)., Conclusion: There is an association between plagiocephaly and neurodevelopmental delay. Primary care professionals should monitor infants with this condition in order to initiate proactive interventions.

The prevalence of positional cranial asymmetry has significantly increased since the introduction of the "Back to Sleep" campaign. Some deformities require therapeutic measures, such as growth-guiding head prostheses. The diagnosis is based on the clinical features, a thorough clinical examination and measurement of the infant's head. Prevention includes early education of parents about alternative positioning methods. Early interventions such as positioning therapy and physiotherapy can be effective in mild cases. In severe cases, the use of growth-guiding orthoses is necessary. The treatment and timing are crucial as head growth is highest in the first year of life. Helmet treatment should be started early to achieve optimal results in order to achieve an improvement in the head shape and ear position. Multidisciplinary approaches including physiotherapy and osteopathy are essential., (© 2024. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Importance: This is the first population-based study quantifying the incidence of nonsynostotic positional plagiocephaly and/or brachycephaly (PPB) in infancy and its association with developmental disorders., Objective: To report the incidence of PPB before age 1 year, the incidence of craniosynostosis, and the percentage of children with PPB diagnosed with a developmental disorder by age 7 years., Design, Setting, and Participants: This was a retrospective, population-based cohort study of children in the Rochester Epidemiology Project (REP) born in Olmsted County, Minnesota, from January 1, 2008, through December 31, 2012, with follow-up through age 7 years. Data were analyzed from March 2021 to April 2024., Exposure: Physical examination detecting cranial deformity., Main Outcomes and Measures: The primary outcome was the incidence of PPB. Secondary outcomes were the incidence of craniosynostosis and the percentage of children with PPB diagnosed with a developmental disorder by age 7 years., Results: Of 9909 infants (5084 [51.3%] male; 9205 [92.9%] born at term and 704 [7.1%] born preterm) included in the study, 575 had PPB, for a PPB incidence of 5.8% (95% CI, 5.3%-6.3%). The incidence of PPB was 5.3% (95% CI, 4.8%-5.8%) in term infants vs 11.8% (95% CI, 9.4%-14.6%) in preterm infants. The incidence of craniosynostosis was 0.16% (95% CI, 0.09%-0.26%). A developmental disorder was known or suspected in 4.2% (95% CI, 2.7%-6.2%) of infants at the time of PPB diagnosis; among 402 infants with PPB and follow-up through age 7 years, 30 (7.5%; 95% CI, 5.0%-10.7%) had a confirmed developmental disorder by 7 years of age. The prevalence of autism spectrum disorder (ASD) in children with a history of PPB who were followed up to age 7 years was 2.2% (9 of 402 children)., Conclusions and Relevance: This study found that only a small percentage of the infants had positional head deformity significant enough to be documented and/or referred for subspecialty evaluation, and only a small subset of these children went on to have a developmental disorder in childhood. This information is helpful for counseling families about their child's developmental risk at time of PPB diagnosis.

Objective: To estimate the occurrence and severity of deformational plagiocephaly among infants., Methods: A hospital-based, cross-sectional study was done in the pediatric ward of a tertiary care hospital between April 1, 2022 to October 31, 2022. Cranial Vault Asymmetry Index (CVAI) and Argenta Clinical Classification were applied to consecutive infants aged 1 month to 1 year till the calculated sample size was achieved., Results: 67 infants were recruited and the occurrence of deformational plagiocephaly in the sample was estimated to be 46.3%. Level 2 severity of deformational plagiocephaly was the commonest, while as per the Argenta classification, majority belonged to type I (39.2%). Male gender and developmental delay were the significant risk factors for plagiocephaly with an odds ratio (95% CI) of 3.73 (1.23, 11.26) and 19.25 (2.31, 160.3), respectively., Conclusion: A high occurrence of deformational plagiocephaly was found in infants studied. There is a need for more studies to further corroborate these findings and study its associated factors.

Introduction: The American Academy of Pediatrics Back-to-Sleep Campaign significantly reduced infant mortality from sudden infant death syndrome. As a result of prolonged supine positioning, the incidence of deformational plagiocephaly has also risen 5-fold since its adoption. We aimed to improve the current educational paradigm for new parents with the goal of reducing the incidence of plagiocephaly within the confines of the Back-to-Sleep Campaign. We hypothesized that the early addition of plagiocephaly focused education for parents would reduce cephalic index, the ratio of head width to length, used as an easily measured objective proxy for positional plagiocephaly., Methods: Children were screened at their newborn visit. Premature newborns and those diagnosed with craniofacial disorders were excluded. For those enrolled, biparietal and anteroposterior measurements of the head were obtained using manual calipers to obtain cephalic index. Subjects randomly assigned to the intervention group were shown a 2-minute video and given an educational pamphlet on methods to prevent plagiocephaly. Unpaired 2-sample t tests comparing mean differences in intervention and control were performed., Results: Thirty-nine subjects were enrolled as of November 2023 with variable lengths of follow-up completed. The average baseline cephalic index for subjects in the control group was 82.7 and 83.8 for intervention group. Unpaired 2-sample t tests were performed at 2-, 4-, and 6-month time points to analyze the difference between groups. At 4 months, average cephalic index for subjects in the control and treatment group, respectively, was 90.6 and 83.4 (P = 0.02)., Significance: Parental education at the newborn visit led to decreases in cephalic index, a proxy for positional plagiocephaly, compared with control patients. This simple intervention has the potential to reduce parental stress and healthcare costs associated with the evaluation and treatment of plagiocephaly., Competing Interests: Conflicts of interest and sources of funding: none declared., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: To study the effects of infantile positional plagiocephaly on the growth and neural development., Methods: A retrospective study was conducted on the medical data of 467 children who underwent craniographic examination and were followed up to 3 years of age in Peking University Third Hospital from June 2018 to May 2022. They were divided into four groups: mild positional plagiocephaly ( n =108), moderate positional plagiocephaly ( n =49), severe positional plagiocephaly ( n =12), and normal cranial shape ( n =298). The general information of the four groups and the weight, length, head circumference, visual acuity screening results, hearing test results, and the scores of Pediatric Neuropsychological Developmental Scales/Gesell Developmental Schedules of the four groups from 6 to 36 months old were compared., Results: The rates of adverse perinatal factors, congenital muscular torticollis, and supine fixed sleeping posture in the mild, moderate, and severe positional plagiocephaly groups were higher than the normal cranial group ( P <0.05). There was no significant difference in weight, length, and head circumference among the four groups at 6, 12, 24 and 36 months of age ( P >0.05). The incidence rate of abnormal vision in the severe positional plagiocephaly group was higher than that in the mild positional plagiocephaly, moderate positional plagiocephaly and normal cranial shape groups at 24 and 36 months of age ( P <0.05). The scores of the Pediatric Neuropsychological Developmental Scales at 12 and 24 months of age and the scores of the Gesell Developmental Schedules at 36 months of age in the severe positional plagiocephaly group were lower than those in the mild positional plagiocephaly, moderate positional plagiocephaly and normal cranial shape groups, but the difference was not statistically significant ( P >0.05)., Conclusions: Adverse perinatal factors, congenital muscular torticollis, and supine fixed sleeping position may be associated with infantile positional plagiocephaly. Mild or moderate positional plagiocephaly has no significant impact on the growth and neural development of children. Severe positional plagiocephaly have adverse effects on the visual acuity. However, it is not considered that severe positional plagiocephaly can affect the neurological development.

Since the American Academy of Pediatrics recommended the supine sleeping position for infants to prevent SIDS, positional plagiocephaly (PP) prevalence has increased. There are great controversies regarding the possible consequences of PP and the degree of severity required for them to manifest. There is no consensus on the efficacy of PP therapies, such as positioning, kinesiology, and cranial orthoses. This review aims to analyze the existing literature to update the causes, main characteristics, and evidence on the treatment of PP. Intervention from the newborn period is important, encompassing both prevention and management education, as well as early screening, evaluating the possible presence of congenital muscular torticollis, to start early treatment. The presence of PP can be a risk marker for psychomotor development.

Along with the decrease in sudden infant death syndrome due to the successful "Back to Sleep" Campaign, there was a reciprocal increase in cases of positional plagiocephaly (PP). The prevalence of PP significantly rose from approximately 5% to upward of 46% at age 7 months. Consequently, clinicians have seen a surge in the number of patients presenting with head shape abnormalities. Not only does this increase in patient volume pose a logistical problem to clinics, but it also poses a potential risk to patients with craniosynostosis, whose head shape anomalies are similar to a "needle in a haystack" of patients with more common PP. This review explores the causes, risk factors, and treatment options of PP and craniosynostosis, along with the differential of head shape anomalies based on phenotypic presentation. In doing so, we hope to provide pediatric care clinicians with the tools necessary to effectively evaluate and manage patients with head shape abnormalities. [ Pediatr Ann . 2023;52(1):e10-e17.] .

Introduction: Positional plagiocephaly (PP) is characterized by an asymmetrical flatness of the posterior part of the skull which may involve the frontal part of the skull and the face. The aim is to assess whether children and adolescents with PP have more occlusal and skeletal asymmetries and whether the need for orthodontic treatment is greater than in the healthy population., Material and Method: A comparative cross-sectional epidemiological study was carried out. One hundred children and adolescents were included: 50 in the PP group and 50 in the control group. The need for orthodontic treatment was assessed by the Index of Orthodontic Treatment Need (IOTN). The mandibular and dental asymmetries were measured on lateral cephalometry by two indexes: index of mandibular asymmetry (IMA) and index of dental asymmetry (IDA) respectively. Chi and Student independence tests were performed with a threshold of 5%., Results: The tests are significant for IMA (p = 0.02) and IOTN (p = 0.000012). IDA is insignificant., Discussion: Orthosurgical treatment of mandibular laterognathies by mandibular recentering sometimes creates mandibular asymmetry, while the shift is basal. We must be able to act early on the vault of the skull to hope to obtain a consecutive effect on the base and therefore on the position of the glenoid cavities. Management by manual therapy and early cranial orthosis could be estimated., Conclusion: The need for orthodontic treatment is significantly greater in PP. Unlike mandibular asymmetry, dental asymmetry is not significantly greater than in the control group, testifying to the adaptive capacities of the organism.

Background: The aim of this study was to document the evolution of cranial asymmetries in infants with signs of nonsynostotic occipital plagiocephaly (NSOP) who underwent to many functional manual therapy treatments (in addition to the standard positioning recommendations); as well as to determine the feasibility of this methodology to conduct outcome research investigating the impact of this intervention for infants with NSOP., Methods: This is a pilot clinical standardization project using pre-post design in which 10 infants participated. Nine infants presented an initial Oblique Diameter Difference Index (ODDI) (over 104%), three an initial Ear Deviation Index (EDI) (over 4%), and three a Cranial Proportional Index (CPI) (over 90%). Infants received three functional manual therapy treatments for week during the first month of intervention and two for week during the second month., Results: Plagiocephalometric measurements were administered at the first assessment preintervention (T0), after 30 days (±5) (T1) and at a third time after 60 days (±5) of treatment (T2). Nine out of ten participants showed a significant decrease in ODDI under 104% between T0 and T2 assessments. Five out of ten infants showed an EDI under 4%, and 3/10 showed a value about 0%. 3/10 maintained their CPI over 90% with a considerable decrease., Conclusions: These clinical findings support the hypothesis that functional manual therapy treatments contribute to the improvement of cranial asymmetries in infants younger than 6.5 months old presenting with NSOP.

This article summarizes the current state of diagnostic modalities for infant craniofacial deformities and highlights capable diagnostic tools available currently to pediatricians., Competing Interests: FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose., (Copyright © 2022 by the American Academy of Pediatrics.)

Cranial deformation and deformational plagiocephaly (DP) in particular affect an important percentage of infants. The assessment and diagnosis of the deformation are commonly carried by manual measurements that provide low interuser accuracy. Another approach is the use of three-dimensional (3D) models. Nevertheless, in most cases, deformation measurements are carried out manually on the 3D model. It is necessary to develop methodologies for the detection of DP that are automatic, accurate and take profit on the high quantity of information of the 3D models. Spherical harmonics are proposed as a new methodology to identify DP from head 3D models. The ideal fitted ellipsoid for each head is computed and the orthogonal distances between head and ellipsoid are obtained. Finally, the distances are modelled using spherical harmonics. Spherical harmonic coefficients of degree 2 and order - 2 are identified as the correct ones to represent the asymmetry characteristic of DP. The obtained coefficient is compared to other anthropometric deformation indexes, such as Asymmetry Index, Oblique Cranial Length Ratio, Posterior Asymmetry Index and Anterior Asymmetry Index. The coefficient of degree 2 and order - 2 with a maximum degree of 4 is found to provide better results than the commonly computed anthropometric indexes in the detection of DP., (© 2022. The Author(s).)

Background: The extent of facial involvement in positional plagiocephaly is only little investigated so far. Investigation methods that take into account the challenging anatomical conditions and growth of infants' faces are desirable. In this study, the authors established a new three-dimensional photogrammetry quantification method evaluating pretherapeutic and posttherapeutic facial asymmetry in positional plagiocephaly. Furthermore, a facial asymmetry index was established and evaluated., Methods: Three-dimensional photographs of 100 children undergoing treatment with head orthoses were analyzed by constructing a standardized interindividual coordinate system. Defining landmarks, section planes, and point coordinates with a computer-aided design software, both sides of the faces were compared. Facial asymmetry was quantified by measuring differences between left and right sides and pretherapeutic and posttherapeutic changes in each patient. The facial asymmetry index was calculated by putting the absolute differences in relation with the coordinates of the nonaffected side., Results: Present results indicate that positional plagiocephaly results in a distinct facial asymmetry (range, -3.8 to 9.6 mm) in nearly all spatial directions and facial regions. Helmet therapy led to a significant reduction (p < 0.05) of intraindividual facial asymmetry (median change in facial asymmetry index, -1.9 to 3.1 percent). However, no correlation of the Cranial Vault Asymmetry Index and facial asymmetry (Spearman rank correlation coefficient, ρ = -0.09 to 0.47) has been seen. According to these results, severe occipital deformation does not necessarily provoke distinct facial asymmetry., Conclusions: Present three-dimensional photogrammetry method allows the longitudinal quantification of facial involvement in positional plagiocephaly. Asymmetry has been determined in all facial regions. The facial asymmetry decreased through helmet therapy but was not eliminated completely., (Copyright © 2021 by the American Society of Plastic Surgeons.)

Objective: The aim of this study was to carry out a quantitative analysis of a virtual craniofacial clinic during the COVID-19 pandemic., Methods: The charts of 90 patients from a single institution were reviewed. Of these patients, 45 visited the virtual clinic during the COVID-19 pandemic. The other 45 patients visited the clinic in the 3 months prior to COVID-19. Demographics including the mean age at the visit, chief complaint, visit diagnosis, appointment duration, helmet usage, accuracy of the diagnosis, need for a CT scan, and the need for a follow-up appointment were assessed. Diagnostic accuracy, the frequency of follow-up appointments, and patient satisfaction (via survey), as well as additional associated factors, were analyzed to determine the efficacy and satisfaction associated with the virtual clinic approach., Results: The mean patient age at time of the visit was 5.6 and 7.3 months (p = 0.244), and the mean time from referral to appointment was 19.2 and 19 days (p = 0.934), in the in-person and virtual cohorts, respectively. There was no significant difference in the variety of chief complaints between the in-person and virtual visits, with 97.8% and 93.3% of patients' parents reporting abnormal head shape, respectively, and the remainder reporting more infrequent complaints (p = 0.435). The visit diagnosis was plagiocephaly in 93.3% of the in-person cohort and 80.0% of the virtual cohort (p = 0.118). The final diagnosis exhibited a similar pattern, with 95.6% of the in-person cohort and 88.9% of the virtual cohort observed as positional plagiocephaly; the remaining diagnoses were more infrequent (p = 0.434). The most common alternative diagnosis in the virtual visit cohort was a metopic ridge (8.4%). In the in-person visit cohort, the most common alternative diagnosis was equally a benign enlargement of the subarachnoid space in infancy, scalp mass, and skull lesion (2.2% each). None of the patients in either cohort were diagnosed with synostosis. Eighty percent of the in-person visits were 15 to 30 minutes in duration, with the remaining 20% being 31 minutes or longer; virtual visits were all 30 minutes or less, with 95.6% being 15 to 30 minutes (p = 0.002). Helmets were prescribed for 2 patients in the in-person cohort and no patients in the virtual cohort (p = 0.494). Alterations in diagnosis were made in 2.2% of in-person visits and 6.7% of virtual visits (p = 0.616). Follow-up was required in 15.6% of the in-person visits and 31.1% of the virtual visits (p = 0.134). CT was only utilized twice, once in the in-person visit cohort and once in the virtual visit cohort., Conclusions: Virtual clinic encounters resulted in comparable diagnostic accuracy. The trend toward frequent follow-up assessments and changes in the final diagnosis in the virtual clinic cohort has indicated a level of diagnostic uncertainty via the virtual interface, which required in-person assessment for confirmation. This finding did not contribute toward diagnostic inaccuracy with respect to missed synostosis. The study results have indicated that telemedicine can be an effective modality in assessing craniofacial pathology.

The Safe to Sleep campaign started in 1994, reducing the risk of sudden infant death syndrome (SIDS) by 40% to 60%. However, an undesirable consequence has been a 400% to 600% increase in positional head deformities. We review the risks for positional plagiocephaly or brachycephaly, treatment modalities, and when to refer. Differential diagnoses for non-positional deformities are discussed. Risks for positional head deformities include prenatal, perinatal and postnatal factors. These include torticollis, inadequate tummy time, abnormal intrauterine positioning, premature or postmature birth, prolonged labor, complex medical conditions, prolonged hospitalizations, developmental delay, and use of supportive or convenience devices. Recommended treatment involves repositioning techniques or physical therapy with or without helmet use. Early referral to physical therapy or a head shape program insures better outcomes for full correction of the deformity. The severity of residual deformities is directly related to the age at which the child is referred. [Pediatr Ann. 2020;49(10):e440-e447.]., (Copyright 2020, SLACK Incorporated.)

Background: Although the benefits of helmet therapy for positional plagiocephaly are strongly correlated with age, the effective period remains controversial. However, most physicians agree that effective results can be obtained in patients within the age of 6 months. Owing to the characteristics of positional plagiocephaly in Koreans, many Korean patients have delayed diagnosis, and because this results in delayed onset of the helmet therapy, the outcomes remain largely underevaluated. In the management of late-diagnosed positional plagiocephaly, we aimed to determine the factors affecting the effective application of helmet therapy., Methods: We recruited 39 consecutive patients with positional plagiocephaly who received helmet therapy and completed the treatment between December 2008 and June 2016. The ages at initiation and completion of treatment, duration of daily use, initial and final absolute diagonal differences, cephalic index, and cranial vault asymmetry index (CVAI) were analysed using data retrospectively collected from the patients' medical records., Results: We identified 12 patients with late-diagnosed positional plagiocephaly, of whom 83.33% were effectively treated. The effective change in CVAI (%) was affected by age at treatment initiation ( P = 0.001), initial absolute diagonal distance differences ( P < 0.001), and initial CVAI ( P < 0.001). Up to 9 months, a gradual change of at least 1% CVAI was attained. Treatment initiation at ages < 5.5 months was beneficial. Even at a later age, patients with an initial absolute diagonal distance difference of > 13.50 mm and initial CVAI of > 11.03% could receive effective helmet therapy., Conclusion: The efficacy of helmet therapy in late-diagnosed patients can be predicted on the basis of not only age at treatment initiation, but also initial absolute diagonal distance differences and initial CVAI. We anticipate that even patients with late-diagnosed positional plagiocephaly can expect better helmet therapy outcomes., Competing Interests: The authors have no potential conflicts of interest to disclose., (© 2020 The Korean Academy of Medical Sciences.)

Background: The incidence of positional plagiocephaly has increased significantly over the last two decades, which has caused a service delivery challenge for pediatric neurosurgeons. As a potential solution to the long waitlists for abnormal head shape, a plagiocephaly clinic was established at BC Children's Hospital (BCCH) in Vancouver, Canada. This clinic was supervised by an occupational therapist who had been trained by a neurosurgeon to independently assess and manage patients with a referring diagnosis of positional plagiocephaly., Objectives: To determine the efficiency of the BCCH Plagiocephaly Clinic in the management of positional plagiocephaly patients and to investigate the clinic's ability to appropriately identify and refer patients with craniosynostosis to pediatric neurosurgeons for further assessment., Methods: A retrospective chart review was conducted to identify patients who were assessed and managed at the BCCH Plagiocephaly Clinic between 2008 and 2014. Data on patient demographics, head shape measurements, and treatment recommendations were collected, and the BC Children's neurosurgical database was cross-referenced to identify craniosynostosis cases missed by the Plagiocephaly Clinic. A descriptive analysis of the clinic's average wait times, severity of the patients' plagiocephaly, and recommended interventions was conducted. In addition, the sensitivity and specificity of the clinic's ability to appropriately refer craniosynostosis patients to pediatric neurosurgery were calculated., Results: Of 1752 patients seen in the BC Children's Plagiocephaly Clinic between 2008 and 2014, 66% of patients received counseling about repositioning, 34% were referred for head banding, 19% were referred to physiotherapy for torticollis, and 1.4% were referred to the BC Children's Pediatric Neurosurgery Clinic for suspicion of craniosynostosis. The mean time from referral to first assessment by the Plagiocephaly Clinic was 41 days, and time from referral by the plagiocephaly clinic to diagnosis of craniosynostosis by a pediatric neurosurgeon was 8 days. Pediatric neurosurgeons requested imaging for 6 of the referred patients (25% ). The sensitivity and specificity of the plagiocephaly clinic for referral of craniosynostosis patients to the Pediatric Neurosurgery Clinic were 100 and 99%, respectively., Conclusion: The BC Children's Plagiocephaly Clinic is efficient and safe for the initial evaluation and treatment of patients with positional plagiocephaly. The clinic's model decreases wait times, appropriately manages patients with positional plagiocephaly, screens for craniosynostosis with high sensitivity and specificity, and takes pressure off outpatient neurosurgical clinics. This model for assessment of plagiocephaly could be considered in other medical centers.

Background: Research has focused on the presence of nonsynostotic head deformities (NHD: plagiocephaly, dolichocephaly, brachycephaly) in preterm infants at discharge and within the first year after discharge. However, there is limited data on NHD in preterm neonates during neonatal intensive care unit (NICU) stay., Aim: To acquire quantitative data on head shapes among preterm neonates during NICU hospital stay., Study Design: Investigators performed weekly head measurements on 68 premature infants starting within two weeks of birth or when medically stable until discharge. Infants recruited for the study were born at <34 weeks gestational age., Outcome Measures: Cranial index (CI) and cranial vault asymmetry index (CVAI) were calculated from Ballert cranial caliper measurements during the infants stay (27 to 40 weeks postmenstrual age) in the NICU/Special Care Nursery (SCN) setting. Inter-rater retest reliability was determined for CI and CVAI., Results: Throughout the measurement period, CI consistently demonstrated dolichocephaly (CI < 0.76), and CVAI fluctuated above and below the range indicating plagiocephaly (CVAI ≥ 3.5%). Good to acceptable levels of test-retest reliability was demonstrated; prevalence of dolichocephaly and plagiocephaly at discharge was 82% and 36%, respectively; and mean head dimension measurement time for different combinations of bed types and support systems ranged from 1.1 to 1.9 min., Conclusions: Following the progression of CI and CVAI during the NICU stay using the cranial caliper method is reliable, and a substantial presence of NHD was reported., (Copyright © 2019. Published by Elsevier B.V.)

Purpose: With an increase in positional plagiocephaly patients, various therapy methods have been researched and helmet therapy is the most widely used and effective treatment method. To devise a method that would allow medical professionals and patients' parents to more easily identify the shape and outcomes before and after the therapy., Methods: This study included 399 patients who had helmet therapy from November 2014 to February 2016. Patients wore a cast helmet for more than 20 hours per day. A cranial caliper was used to measure their head before they wore the helmet (prehelmet), once a month during outpatient visits, and 6 months after they stopped wearing the helmet (posthelmet). Clinical photographs were taken on a transparent acrylic sheet with a grid of 5-mm intervals to measure cranial vault asymmetry (CVA), cranial vault asymmetry index (CVAI), and symmetry ration (SR). The patients' photographs were then measured twice: first against the background without the grid and then against the background with the grid., Results: Average age at prehelmet was 20 weeks while their average therapy period was 12 weeks. Patients' prehelmet CVA was 13.3 mm, and their posthelmet CVA was 3.1 mm. Their prehelmet CVAI was 10.1%, and their posthelmet CVAI was 2.1% (P < 0.001). Their overall prehelmet and posthelmet SRs were 0.820 and 0.969, respectively (P < 0.001). In addition, the measurements based on clinical photographs with and without the grid were compared using Fleiss kappa. The results showed κ = 0.847 and 0.956 when the patient was mild, κ = 0.744 and 0.919 when it was moderate, and κ = 0.767 and 0.924 when it was severe (P < 0.001). In all 3 patients, the consistency was higher with the grid., Conclusion: Since cast helmet manufacturing for positional plagiocephaly therapy does not require computed tomography scanning, there is no need to administer a sedative, nor does it pose any radiation exposure risk. Since the cast helmet is easier to manufacture and operate and is more cost effective, it could be used to treat more people. In addition, it would be useful for both medical professionals and patients' guardians to use clinical photographs with the acrylic sheet with the grid as a method to analyze shapes and outcomes before and after therapy, along with traditional CVA and CVAI.

Background: The incidence of plagiocephaly has increased in the 25 years since the "Back to Sleep" campaign in 1991 to prevent sudden infant death. Plagiocephaly is not considered to be a pathological condition. It is more of an esthetic impairment and could have potentially negative psychological or psychosocial consequences; therefore, treatment is recommended. The aim of this study is to compare conventional anthropometry and laser scanning - two different measurement methods - as diagnostic instruments for plagiocephaly. The present study also tests the measurement time of both methods and whether one method is easier on the patient than the other., Material and Methods: A total of 44 children (21 girls, 23 boys) with a mean age of 8.8 months were involved in the present study. Of all patients, the following parameters were routinely evaluated using a standard protocol with the conventional anthropometric method and the scan method: head circumference, head length, head width, head diagonals, and distances ex-t. Furthermore, the time required to obtain measurements and the behavior of the children during measurement were documented. For statistical analysis, a t-test and a Wilcoxon test were used to analyze differences between the two methods., Results: The results for head circumference showed a mean of 441.5 mm for the anthropometric measurements and 441.6 mm for the scan method, with no significant difference between the two methods. A significant difference was found regarding the head width, head length, diagonals, and distance ex-t. The measurement process using the scan method needed a mean of 579.6 s in contrast to the manual anthropometric method, which required a mean time of 180.5 s., Discussion: In comparison with the conventional anthropometric method, measurements made with a 3D laser scanner yield inconsistent results. Moreover, the current state of technology of 3D cephalometry has no advantages compared with the conventional anthropometric method. Disadvantages worth mentioning appear to be the higher technical outlay and the considerable acquisition, service, and maintenance costs., (Copyright © 2017 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Studies have attempted to categorize infant cranial asymmetry in a variety of ways using both observational and quantitative techniques, but none have created a clinical tool that can serve as a treatment guide based on clinical outcomes. In 2006, a research team from Children's Healthcare of Atlanta published the results of a prospective analysis of 224 patients with cranial asymmetries and their treatment outcomes. As a continuation of the previous work, the researchers have identified a plagiocephaly severity scale based on those outcomes to assist medical professionals who treat patients with cranial abnormalities. Our hypothesis is to validate the proposed severity scale that categorizes the clinical presentation and severity of plagiocephaly.Of the 224 patients enrolled, 207 patients were placed in an experimental group and 17 patients who refused treatment were placed in a control group. Digital head shape data were collected. Cross-correlation matrices were computed across variables and regression models resulted in the identification of 5 meaningful variables. A 5-level clinical classification scale was created. Five 1 × 5 analyses of variance were computed to compare each classification level.Four of the 5 analyses of variance identified significant overall effects for classification. A model was developed from the empirical data and the model was tested for accuracy, resulting in 12.1% overall error. The model was validated for both experimental and control groups.The results show that the severity scale is a meaningful outcome-based scale that assists clinicians in developing a treatment plan for treating plagiocephaly. The scale has been validated across a large heterogeneous study sample.

Deformational plagiocephaly (DP) is a common condition and the leading cause of head shape abnormalities in infants. It is characterized by asymmetrical distortion of the skull resulting from external forces on the back of the head. DP has become more prevalent in infants and has increased dramatically since the introduction in 1994 of the “Back to Sleep” campaign. Management of this condition is not often covered by insurance, and can be costly and lengthy; However, DP can be prevented. Early recognition and management can make a significant difference in patients’ outcomes and reduce the cost of treatment. Nurses play a key role in recognition and prevention, are instrumental in educating parents and caregivers, and have a significant impact on preventing and reducing the risk of DP. Current systematic approaches to clinical assessment, diagnosis, and management strategies of DP can help nurses who care for infants and their families understand DP and take the necessary steps to prevent it.

OBJECTIVE Following institution of the Back to Sleep Campaign, the incidence of sudden infant death syndrome decreased while the prevalence of positional skull deformation increased dramatically. The management of positional deformity is controversial, and treatment recommendations and outcomes reporting are variable. The authors reviewed their institutional experience (2008-2014) with the treatment of positional plagiocephaly to explore factors associated with measured improvement. METHODS A retrospective chart review was conducted with risk factors and treatment for positional head shape deformity recorded. Univariate and multivariate analyses were used to assess the impact of these variables on the change in measured oblique diagonal difference (ODD) on head shape surface scanning pre- and posttreatment. RESULTS A total of 991 infants aged less than 1 year were evaluated for cranial positional deformity in a dedicated clinical program. The most common deformity was occipital plagiocephaly (69.5%), followed by occipital brachycephaly (18.4%) or a combination of both deformities (12.1%). Recommended treatment included repositioning (RP), physical therapy (PT) if indicated, or orthotic treatment with a customized cranial orthosis (CO) according to an age- and risk factor-dependent algorithm that the authors developed for this clinic. Of the 991 eligible patients, 884 returned for at least 1 follow-up appointment. A total of 552 patients were followed to completion of their treatment and had a full set of records for analysis: these patients had pre- and posttreatment 2D surface scanner evaluations. The average presenting age was 6.2 months (corrected for prematurity for treatment considerations). Of the 991 patients, 543 (54.8%) had RP or PT as first recommended treatment. Of these 543 patients, 137 (25.2%) transitioned to helmet therapy after the condition did not improve over 4-8 weeks. In the remaining cases, RP/PT had already failed before the patients were seen in this program, and the starting treatment recommendation was CO. At the end of treatment, the measured improvements in ODD were 36.7%, 33.5%, and 15.1% for patients receiving CO, RP/PT/CO, and RP/PT, respectively. Univariate analysis showed that sex, race, insurance, diagnosis, sleep position preference, torticollis history, and multiple gestation were not significantly associated with magnitude of ODD change during treatment. On multivariate analysis, corrected age at presentation and type of treatment received were significantly associated with magnitude of ODD change. Orthotic treatment corresponded with the largest ODD change, while the RP/PT group had the least change in ODD. Earlier age at presentation corresponded with larger ODD change. CONCLUSIONS Earlier age at presentation and type of treatment impact the degree of measured deformational head shape correction in positional plagiocephaly. This retrospective study suggests that treatment with a custom CO can result in more improvement in objective measurements of head shape.

OBJECTIVE This study aimed to examine factors associated with adherence to recommended treatment among pediatric patients with positional skull deformity by reviewing a single-institution experience (2007-2014) with the treatment of positional plagiocephaly. METHODS A retrospective chart review was conducted. Risk factors, treatment for positional head shape deformity, and parent-reported adherence were recorded. Univariate and multivariate analyses were used to assess the impact of patient clinical and demographic characteristics on adherence. RESULTS A total of 991 patients under age 12 months were evaluated for positional skull deformity at the Texas Children's Hospital Cranial Deformity Clinic between 2007 and 2014. According to an age- and risk factor-based treatment algorithm, patients were recommended for repositioning, physical therapy, or cranial orthosis therapy or crossover from repositioning/physical therapy into cranial orthosis therapy. The patients' average chronological age at presentation was 6.2 months; 69.3% were male. The majority were white (40.7%) or Hispanic (32.6%); 38.7% had commercial insurance and 37.9% had Medicaid. The most common initial recommended treatment was repositioning or physical therapy; 85.7% of patients were adherent to the initial recommended treatment. Univariate analysis showed differences in adherence rates among subgroups. Children's families with Medicaid were less likely to be adherent to treatment recommendations (adherence rate, 80.2%). Families with commercial insurance were more likely to be adherent to the recommended treatment (89.6%). Multivariate logistic regression confirmed that factors associated with parent-reported adherence to recommended treatment included primary insurance payer, diagnosis (plagiocephaly vs brachycephaly), and the nature of the recommended treatment. Families were less likely to be adherent if they had Medicaid, a child with a diagnosis of brachycephaly, or were initially recommended for cranial orthosis therapy than families with commercial insurance, a child with a diagnosis of plagiocephaly, or an initial recommendation for repositioning or physical therapy. Factors associated with treatment completion included corrected age, insurance, diagnosis, recommended treatment, and distance to provider from patient's residence. Patients with commercial insurance (OR 1.49, 95% CI 1.10-2.02, p = 0.009), those diagnosed with both brachycephaly and plagiocephaly (OR 2.26, 95% CI 1.31-3.90, p = 0.003), those recommended for treatment with cranial orthosis (OR 4.55, 95% CI = 3.24-6.38, p < 0.001), and those living in proximity to the provider (OR 1.40, 95% CI 1.00-1.96, p = 0.047) were more likely to complete treatment. CONCLUSIONS Insurance type, degree of head shape deformity, and types of recommended treatment appear to affect rates of adherence to recommended treatments for positional skull deformation.

Purpose: Positional plagiocephaly (PP) is the most common subtype of asymmetric deformity in the infant skull. Cumulative evidence has demonstrated that PP is associated with abnormal neuromotor development; however, neurological assessment scores of infants with PP have not been well established, and PP has not attracted sufficient attention in China. This study used a Chinese version of the Infant Neurological International Battery (INFANIB) to identify neurological abnormalities among infants with PP and to determine the differences between infants with different (mild, moderate, and severe) degrees of PP., Methods: We compared the neurological evaluation scores between 393 infants with different degrees of PP and 390 healthy infants from 0 to 18 months of age using a Chinese version of the INFANIB., Results: The infants with PP aged 0-7.9 months had lower scores on the spasticity, head and trunk, leg, and French angle subscales and lower total scores than the normal infants. Additionally, the infants with PP aged 9-18 months showed statistically significantly lower scores on the spasticity, head and trunk, vestibular function, leg, and French angle subscales and total scores than the normal infants. Among the PP subgroups, the infants with mild PP had the highest scores, followed by the infants with moderate PP and the infants with severe PP. Compared with the normal infants, the infants with PP had abnormal neurological assessment scores, and the degree of neurological abnormality was associated with the severity of PP., Conclusions: The INFANIB revealed neurological abnormalities, including asymmetric movements and abnormal muscle tone, postures, and reflexes, in infants with PP, especially those with moderate or severe PP. These abnormalities were similar to those of infants with cerebral palsy. Therefore, PP may serve as a marker of neurodevelopmental risk and should receive considerable attention. Whether moderate or severe PP is related to cerebral palsy remains to be confirmed in long-term follow-up studies and other future studies.

In a continuation of a prospective longitudinal cohort study in a healthy population on the course of skull shape from birth to 24 months, at 5 years of age, 248 children participated in a follow-up assessment using plagiocephalometry (ODDI-oblique diameter difference index, CPI-cranio proportional index). Data from the original study sampled at birth, 7 weeks, 6, 12, and 24 months were used in two linear mixed models., Main Findings: (1) if deformational plagiocephaly (ODDI <104%) and/or positional preference at 7 weeks of age are absent, normal skull shape can be predicted at 5 years of age; (2) if positional preference occurs, ODDI is the highest at 7 weeks and decreases to a stable lowest value at 2 and 5 years of age; and (3) regarding brachycephaly, all children showed the highest CPI at 6 months of age with a gradual decrease over time., Conclusion: The course of skull deformation is favourable in most of the children in The Netherlands; at 5 years of age, brachycephaly is within the normal range for all children, whereas the severity of plagiocephaly is within the normal range in 80%, within the mild range in 19%, and within the moderate/severe range in 1%. Medical consumption may be reduced by providing early tailored counselling. What is Known: • Skull deformation prevalence increased after recommendations against Sudden Infant Death Syndrome, little is known about the longitudinal course. • Paediatric physical therapy intervention between 2 and 6 months of age reduces deformational plagiocephaly at 6 and 12 months of age. What is New: • The course of skull deformation is favourable in most of the children in The Netherlands; at 5 years of age, deformational brachycephaly is within the normal range for all children, whereas the severity of deformational plagiocephaly is within the normal range in 80%, within the mild range in 19%, and within the moderate to severe range in only 1%. • Paediatric physical therapy intervention does not influence the long-term outcome; it only influences the earlier decrease of the severity of deformational plagiocephaly., Competing Interests: Compliance with ethical standards All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. The Medical Ethics Committees of the University Medical Center Utrecht, The Netherlands (initial part of the study 0–24 months), of the Radboud University Medical Center Nijmegen, The Netherlands (5-year assessments) and of the Bernhoven Hospital Veghel (all assessments), The Netherlands, gave ethical approval. Written informed consent was obtained from all parents of the children in the cohort. Funding This study was made possible by a grant BU002/10 from the Scientific Committee of The Royal Dutch Association for Physiotherapy, Amersfoort, The Netherlands. There was independence of researchers from funders. Conflict of interest The authors declare that they have no conflicts of interest. The authors have indicated they have no financial relationships relevant to this article to disclose.

Deformational plagiocephaly (DP) in infants has been associated with developmental delay that can last until adolescence. Despite this association and a 5-fold increase in incidence of DP over the past 2 decades, there are currently no guidelines regarding screening for developmental delay or identification of which infants with DP are at the greatest risk of delay. A prospective, nonrandomized study was performed. Infants diagnosed with DP who had no prior intervention were eligible for enrollment. Cranial deformity was measured by cross-cranial measurements using calipers, and developmental delay was measured using the Bayley Scales of Infant and Toddler Development, Third Edition (Bayley-III). Correlation between cranial deformity and developmental delay was analyzed using a linear regression. Twenty-seven infants, ages 4.0 to 11.0 months (mean = 6.61 months) diagnosed with DP were studied. Developmental delay was observed on the composite language (n = 3 of 27, 11%), and composite motor (n = 5 of 23, 22%) scales, but not the cognitive scale. Severity of cranial deformity did not correlate with scores on any Bayley-III scales (cognitive R = 0.058, P = 0.238; composite language R = 0.03, P = 0.399; composite motor R = 0.0195, P = 0.536). This study demonstrates that severity of cranial deformity cannot be used to predict presence or degree of developmental delay. Craniofacial surgeons should be aware of this risk and consider developmental screening based on clinical suspicion.

This article provides an overview of etiology, epidemiology, pathology, diagnosis, and treatment of nonsyndromic craniosynostosis, including sagittal, metopic, coronal, lambdoid, and complex synostosis. Detailed discussion is presented regarding indications for surgical intervention and management options, including frontoorbital advancement, cranial vault reconstruction, endoscopic strip craniectomy, spring-assisted strip craniectomy, and cranial vault distraction osteogenesis. Deformational plagiocephaly is also presented with treatment options including repositioning, physical therapy, and helmet therapy., (Copyright © 2016 Elsevier Inc. All rights reserved.)

This article provides an evidence-based review of the literature concerning the cause, diagnosis, manifestations, and treatment of nonsynostotic plagiocephaly, with a particular focus on recently published studies of helmet therapy. It is designed to serve as an overview of this very common abnormality and a stimulus for discussion about management paradigms and future research priorities.

The severity of deformational plagiocephaly is frequently measured by cranial vault asymmetry (CVA). Cranial vault asymmetry is a simple linear proxy for the three-dimensional deformity. Different anthropometric landmarks have been suggested as the endpoints of the cross-cranial diagonals that determine CVA. One promising albeit counterintuitive set of digital landmarks is the frontozygomaticus and contralateral eurion. The validity of nondigital caliper measures associated with the diagonals defined by the frontozygomaticus and contralateral eurions has not been tested. In this study, the authors compare caliper measures against stereophotogrammetric measures that have been documented to correlate strongly with overall skull asymmetry.Cranial vault asymmetry was assessed by direct anthropometry with 2 different measures on 36 patients. Frontozygomaticus and contralateral eurion (fz-eu) and 30 degrees off the anteroposterior diameter (30offAP). Three-dimensional photographs were obtained and also used to quantify CVA in these subjects; digital measures of fz-eu and an overall measure of plagiocephaly (Global) were calculated. Global and 30offAP obtained at 31 patient visits in 2011 were also included.The measure best-correlated with overall Global asymmetry was digital fz-eu (R = 0.80). Caliper fz-eu was not strongly correlated with Global asymmetry (R = 0.27) or with digital fz-eu (R = 0.34). Differences between the digital and caliper fz-eu measures were 5 ± 4 mm (mean ± st. dev.). Differences between the caliper fz-eu and 30offAP measures were 6 ± 4 mm.Digital fz-eu shows an excellent correlation to Global asymmetry. However, attempts to replicate this result in the clinical setting by measuring fz-eu with calipers were unsuccessful.

Introduction: Since the initiation of the "Back to Sleep Campaign" by the American Academy of Pediatrics in 1992, the incidence of referrals for positional plagiocephaly has increased by 600%. Although patients with positional plagiocephaly rarely require operative intervention, they often do require treatment with cranial molding helmets or positioning changes. The increased volume of patients makes the task of separating cases of craniosynostosis from positional head shape problems more difficult. The authors sought to determine how providers are handling this increased workload of head shape abnormality patients, especially with respect to the largest practices., Materials and Methods: An electronic survey was created and distributed to members of the American Society of Maxillofacial Surgeons and the American Cleft Palate Association (ACPA). Practices were categorized by head shape patient volume as low (<4 new patients/month), medium (5-20 new patients/month), and high (>21 new patients/month). A Pearson's χ test was used to determine characteristics that differed significantly with practice volume., Results: Response rate was 6.6%, with 88 responses. Regarding head shape evaluation, 17.6% of practices used a laser scanner (portable or stationary), 35.3% used caliper anthropometric measurements, 28.5% used two-dimensional digital photography, and 9.4% used three-dimensional digital photography. In high-volume centers, 80% had a dedicated head shape clinic (P < 0.0005), 33.3% used a stationary laser scanner (P = 0.023), and 53.3% used a licensed independent provider (LIP) such as a nurse practitioner or physician assistant in the initial evaluation of head shape abnormalities (P = 0.032). Although using a multidisciplinary clinic was not a significant difference amongst groups, the most common additional provider in multidisciplinary clinic was orthotics (68%)., Conclusions: High-volume practices are significantly more likely to use LIPs, stationary laser scanners, and plain films, as well as organizing head shape abnormality patients into a dedicated clinic.

Measurement of cranial vault asymmetry (CVA) is a common feature in the treatment of patients with deformational plagiocephaly (DP). In many cases, this measure is the primary marker of improvement. CVA is typically measured with calipers and is subject to interrater variability. There is little research comparing results of calipers with those of three-dimensional (3D) photogrammetry.Fifty nine visits were made by 51 children previously diagnosed with DP. Thirty eight were male and 13 were female. Thirty one of the visits included a 3D photograph. Direct measures were obtained by 2 experienced anthropometrists and included head length, width, circumference, and CVA. Their results were compared to digital measures including measures unobtainable with calipers, asymmetry of head circumference and global asymmetry.The interrater reliability of all caliper measures was excellent (intraclass correlation coefficients > 0.94). Caliper and digital measures of length, width, cephalic index, and circumference were strongly correlated (R > 0.90). There was a consistent bias, caliper measures being 1 to 4 mm shorter than their digital analogues. Caliper measured CVA was highly correlated (R > 0.90) with the directly corresponding digital measures. It was poorly correlated with measures of overall hemispheric asymmetry (R < 0.10).The cranial measurements of children with DP taken independently by 2 experienced anthropometrists showed excellent interrater reliability. Caliper measures are consistently smaller than the digital measures, presumably due to pressure of the calipers and/or the use of skullcaps during photography. Like circumference and other assessments, cranial vault asymmetry measures correlate well with their analogous digital measurements.

Background: When evaluating infants with deformational plagiocephaly, cervical spine radiographs are often acquired along with skull radiographs to exclude segmentation and fusion anomalies as the cause of associated torticollis. The diagnostic yield of cervical spine radiographs has not been evaluated in this clinical setting., Methods: The authors retrospectively reviewed the charts of all patients who were referred to the University of Texas Southwestern School of Medicine, Children's Medical Center (Dallas, Texas) with deformational plagiocephaly and torticollis and underwent cervical radiography (anteroposterior and lateral views) from 2010 to 2012. The authors reviewed the radiology reports, and a single experienced pediatric neuroradiologist again reviewed all radiographic studies in which the interpreting radiologist had suggested any bony or soft-tissue abnormality. Patient demographics, perinatal data, and physical examination findings were collected, and descriptive statistics were calculated., Results: There were 730 patients with deformational plagiocephaly and torticollis; 49 of 730 reports (6.7 percent) described an abnormality. Of those with abnormal radiologic reports that were abnormal, 23 (47 percent) described osseous abnormalities, 20 (41 percent) described nonosseous deformities, and six (12 percent) described both. Follow-up studies (computed tomography, magnetic resonance imaging, and repeated radiography) of those with abnormalities showed three infants with true upper cervical spine anomalies that might lead to instability of the cervical spine., Conclusions: There is a low diagnostic yield in ordering cervical radiographs in most patients with deformational plagiocephaly. Although the radiation exposure is low, cervical radiographs add additional cost and may not be warranted as a routine practice in this clinical setting., Clinical Question/level of Evidence: Diagnostic, IV.

Introduction: A stratification system is useful in deformational plagiocephaly (DP) to help categorize patients and reproduce a consistent treatment strategy. The Argenta classification is a clinical 5-point scale for unilateral DP and 3-point scale for central DP (CDP)., Methods: A retrospective review was completed for patients with DP and classified using the Argenta clinical classification by plastic surgeons at a tertiary medical center over a 12-year period., Results: In the 4483 patients, type III was the most prevalent DP type (42%) followed by II, IV, I, and V. Within CDP, VIB was the most common (6%) followed by VIA and VIC. Right-sided DP (56.8%) was more common than left-sided (28.3%) and bilateral (20.4%) (P < 0.0001). For treatment, 89.8% used molding helmet therapy, 9.3% used positioning only, and 0.4% used sock hat. Helmet use increased with increasing type to 98% with type V. In CDP, there was a significant increase in helmet use between VIA and VIB, but helmet use decreased in VIC. There was a higher rate of positioning only in types I, II, and VIA, which diminished as severity increased. Deformational plagiocephaly corrected to type I or 0 in 83.5% of the patients with the highest correction rate in type I (90.7%). Mean age of correction was 11.4 months and time to correction was 5.7 months. Both significantly increased with severity of type in the patients with DP but not in those with CDP., Conclusions: The Argenta classification scale allows reliable evaluation for cranial deformities and may help predict the optimal type duration of treatment.

Background: Deformational plagiocephaly is cranial asymmetry caused by external forces on the skull. Deformational plagiocephaly is seen in 5% to 48% of healthy newborns. Incomplete uvular fusion, in contrast, is one of many uvular malformations. The incidence of all degrees of incomplete uvular fusion is approximately 1% in healthy children. Bifid uvula is a malformation that is often considered a microform cleft palate or a marker for submucous cleft palate., Methods: This is a retrospective study of patients with deformational plagiocephaly seen at the Upstate Cleft and Craniofacial Center between January 1, 2006, and September 30, 2011. Patients were identified by the International Classification of Diseases, Ninth Revision code for plagiocephaly. Seventy-nine patients were excluded with craniosynostosis and syndromic diagnoses. One hundred forty-six patients with deformational plagiocephaly were included in the study. Data were collected for sex, age at presentation, parity, multiple births, delivery, oligohydramnios, cephalohematoma, uterine abnormalities, fetal position, and intrauterine growth restriction. Clinical findings were collected including location of cranial flattening and uvular malformations., Results: Twenty-four of 146 patients with deformational plagiocephaly had incomplete fusion of the uvula ranging from complete bifid uvula to a notched uvular tip (16.4%). This association was statistically significant (odds ratio, 18; 95% confidence interval, 11.1-28.9). Most patients (62.3%) were male. We recorded primiparity (44.5%), multiple births (17.1%), vacuum-assisted delivery (6.2%), cesarean section (36.3%), oligohydramnios (4.1%), uterine abnormalities (2.1%), abnormal fetal position (3.4%), and intrauterine growth restriction (1.4%). Ten of the 24 patients with plagiocephaly and uvular malformation were seen for an initial consultation only in our chart system. Of the remaining 14 patients with follow-up, none had recorded signs or symptoms of velopharyngeal insufficiency., Conclusions: The incidence of incomplete uvular fusion in infants with deformational plagiocephaly is 16.4%, which is significantly higher than the approximate 1% incidence reported in the general population. This is the first report of uvular malformation in the presence of deformational plagiocephaly.

Background: The authors investigated the effectiveness of conservative (repositioning therapy with or without physical therapy) and helmet therapy, and identified factors associated with treatment failure., Methods: A total of 4378 patients evaluated for deformational plagiocephaly and/or deformational brachycephaly were assigned to conservative (repositioning therapy, n = 383; repositioning therapy plus physical therapy, n = 2998) or helmet therapy (n = 997). Patients were followed until complete correction (diagonal difference <5 mm and/or cranial ratio <0.85) or 18 months. Rates of correction were calculated, and independent risk factors for failure were identified by multivariate analysis., Results: Complete correction was achieved in 77.1 percent of conservative treatment patients; 15.8 percent required transition to helmet therapy (n = 534), and 7.1 percent ultimately had incomplete correction. Risk factors for failure included poor compliance (relative risk, 2.40; p = 0.009), advanced age (relative risk, 1.20 to 2.08; p = 0.008), prolonged torticollis (relative risk, 1.12 to 1.74; p = 0.002), developmental delay (relative risk, 1.44; p = 0.042), and severity of the initial cranial ratio (relative risk, 1.41 to 1.64; p = 0.044) and diagonal difference (relative risk, 1.31 to 1.48; p = 0.027). Complete correction was achieved in 94.4 percent of patients treated with helmet therapy as first-line therapy and in 96.1 percent of infants who received helmets after failed conservative therapy (p = 0.375). Risk factors for helmet failure included poor compliance (relative risk, 2.42; p = 0.025) and advanced age (relative risk, 1.13 to 3.08; p = 0.011)., Conclusions: Conservative therapy and helmet therapy are effective for positional cranial deformation. Treatment may be guided by patient-specific risk factors. In most infants, delaying helmet therapy for a trial of conservative treatment does not preclude complete correction., Clinical Question/level of Evidence: Therapeutic, III.

Background: In 1992, the American Academy of Pediatrics discouraged prone sleeping positions because of its association with sudden infant death syndrome. After this was an increased incidence of deformational plagiocephaly (DP)., Methods: A retrospective review was completed for patients with DP and craniosynostosis seen by plastic surgeons at a tertiary medical center during a 19-year period. Two groups of patients were evaluated before (1988-1995) and after (1996-2007) implementation of the "Back to Sleep" campaign., Results: Of the 5169 patients, those with craniosynostosis (n = 279) had a mean age at initial evaluation before and after 1996 of 12.4 versus 5.6 months (P = 0.0008). There was a trend of decreasing age at initial evaluation and first surgery after 1996. For patients with DP (n = 4890), the mean age at initial evaluation before and after 1996 was 11.5 versus 6.0 months (P = 0.10). There was a trend of decreasing age at initial evaluation and DP correction after 1996. The majority of patients had right-sided DP (50.2%), followed by left-sided (24.7%) and bilateral (18.9%). There was no significant difference in DP correction rate (67% versus 87%) or the mean age that DP was corrected (12.8 versus 11.8 mo) before and after 1996. Compared with 1996 to 1999, there was a 214% and 390% increase in DP referrals from 2000 to 2003 and 2004 to 2007. For craniosynostosis, there was a 27% and 129% increase in referrals., Conclusions: The increasing incidence of DP since the Back to Sleep campaign is concerning, but a positive outcome is that patients are being referred and treated at a younger age.

Introduction: The incidence of torticollis, which is often accompanied by some degree of plagiocephaly in infants, has remained increased since the introduction of the supine sleeping position to prevent sudden infant death. Recently, instruments allowing quantitative measurement of torticollis and related pathology have been developed and validated. The aim of the present study was to monitor a cohort of children with torticollis using a standardised protocol including valid and reliable measurements., Methods: A total of 136 infants diagnosed with torticollis and referred to physiotherapeutic treatment in four paediatric departments were included (October 2009-April 2011). Trained and calibrated physiotherapists assessed their cervical range of motion (ROM), cervical muscle function and severity of plagiocephaly prior to and after the treatment period., Results: The infants' median age was three months at inclusion and seven months at the end of the treatment period that comprised a median of five treatment sessions. Initially, 52% and 54% presented with ROM deficits in rotation and lateral flexion, respectively. After treatment, these parts were reduced to 6% and 14%, and the magnitudes of the remaining ROM deficits were substantially reduced. Plagiocephaly improved in 82, remained unchanged in 18 and deteriorated in five of 105 infants with complete follow-up. Symmetrical or almost symmetrical muscle function was achieved in 93% (n = 101)., Conclusion: A successful outcome was achieved in the majority (90%) of children with torticollis with less than ten physiotherapeutic treatment sessions., Funding: not relevant., Trial Registration: not relevant.

Aim: This study analyses pathomorphological and physiological head shapes and classifies the pathomorphology in positional plagiocephaly and brachycephaly., Patients and Methods: 78 infants with a positional plagiocephaly (5.99 months) and 32 infants with a positional brachycephaly (6.53 months) with a Cephalic index > 94% were investigated in this study and compared to a matched control group of 35 infants. The head shapes were analysed by stereophotogrammetry 3D data., Results: The cephalic index, the total width, and coronal circumference were the highest values in patients with brachycephaly and the lowest values in the control group. The asymmetry of the head showed that the diagonal difference in brachycephalic patients more than doubled, and in patients with plagiocephaly almost tripled compared to the controls. A significantly higher total volume and vertex height was found for the patients with plagiocephaly and the patients with brachycephaly compared to the controls., Conclusion: The cephalic index is a valuable and reliable parameter in order to differentiate positional deformities from unaffected skulls. Pathomorphology of a plagiocephaly is associated with the most severe asymmetry of the head. Plagiocephaly and brachycephaly overlap in several criteria. Therefore it seems justified to speak of a continuum rather than to differentiate between plagiocephaly and brachycephaly., (Copyright © 2014 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Background: Unilateral lambdoid synostosis is considered to be the rarest form of craniosynostosis. Since the introduction of the Sudden Infant Death Syndrome "back to sleep" campaign, the incidence of unilateral lambdoid synostosis was reportedly increasing. This was proven to be false and a consequence of non-specific diagnostic criteria in excluding suture fusion from deformational changes. This, in turn, led to ambiguity in the literature in terms of features and surgical correction in the 1980s to 1990s., Objective of Review: We aimed to navigate the literature for true studies of unilateral lambdoid synostosis and examine the results of their surgical corrections., Type of Review: A systematic review with a defined search strategy., Search Strategy: A search on MEDLINE and Google Scholar using strategy: (Unilateral AND ((lambdoid* AND Synostosis) OR (lambdoid* AND Craniosynostosis) OR (Posterior AND Plagiocephaly)) AND (Surgery)., Evaluation Method: Articles were reviewed, and data were compiled into tables for analysis., Results: Seventeen studies were included in this review. A total of 188 patients with unilateral lambdoid synostosis were identified. No patients had major complications (venous sinus tear, neurologic injury, or cerebrospinal fluid leakage). Facial asymmetry was widely noted, and only limited improvement was achieved postoperatively. Auricular displacement was variable and often persisted despite surgery. Neurodevelopment did not deteriorate postoperatively and even improved in several patients. Endoscopic techniques revealed shorter periods of hospitalization, reduced mean estimated blood loss, and no blood transfusion requirements. The timing of surgery at 6 to 12 months was found to be the optimal balance in preventing deterioration in neurodevelopment and allowing favorable cranial growth and morphology., Conclusions: The current evidence is difficult to navigate because of deformational plagiocephaly being misdiagnosed as unilateral lambdoid synostosis. Despite this, we present the only systematic review of all truly identifiable cases of unilateral lambdoid synostosis. Long-term quantitative studies are required to assess the benefits of the various surgical procedures.

Background: Deformational plagiocephaly (DP) is an asymmetry of the skull caused by extrinsic compression. With the advent of the Back to Sleep campaign, DP is of increased interest to parents and healthcare providers. Traditionally, this asymmetry has been assessed by caliper measurements. However, little consensus exists as to which caliper measures (linear) give the most accurate representation of DP. The purposes of this study are to examine different measures and to determine which have the greatest validity in the assessment of skull asymmetry., Methods: Six linear measures were assessed using 31 three-dimensional photographs of 26 children diagnosed with DP. These measurements were compared with more encompassing measures: a head perimeter measurement, a global three-dimensional measure of hemispheric asymmetry, and the radial symmetry index. These 3 broader measures were used to determine which linear, caliper-style measurements most accurately reflect overall DP., Results: Intrarater reliability of the measurements varied widely (intraclass correlation coefficients from 0.42 to 0.99). Correlations between the measures also varied widely (0.10 < r < 0.95). The linear measure that best correlated with the inclusive measures of asymmetry was FZ-EU, the distance from the frontozygomaticus to the contralateral eurion (r ≥ 0.90)., Conclusions: These data introduce 2 digital measures that might serve as standards against which linear measures of asymmetry may be tested: Global asymmetry and head perimeter measures were strongly correlated to each other. When these 2 parameters were compared against linear measures, FZ-EU was noted to be the best linear measure of asymmetry based on these benchmarks.

Positional plagiocephaly in the newborn corresponds to a posterior flattening and asymetry of the head. Its incidence has significantly increased since the "back to sleep" campain in the nineteen nineties to prevent sudden infant death syndrome. The posterior deformation usually worsens during the first six months of life when the skull is susceptible to posterior constant pressure which induces the deformation. Spontaneous outcome can be favorable. Treatment is always conservative and consists in positionnal exercise, physiotherapy and osteopathy. In some cases treatment with a helmet is recommended for a period of three months usually. Posterior positionnal plagiocephaly has no consequences on the brain's developement an is considered as an esthetic issue. In most cases good results are obtained after management with a custom fitted helmet when needed.

Object: There has been a tremendous increase in the incidence of deformational plagiocephaly in children throughout the world. Therapeutic options include observation, active counterpositioning, external orthotics, and surgery. The current treatment in the US is highly debated, but it typically includes external orthotic helmets in patients with moderate to severe plagiocephaly presenting between 4 and 10 months of age or in children with significant comorbidities limiting passive (no-pressure) therapy. The present study was designed to evaluate 3 key issues: 1) the accuracy of the Argenta classification in defining a progressive degree of severity, 2) identification of an upper age limit when treatment is no longer effective, and 3) the effectiveness of an off-the-shelf prefabricated helmet in correcting deformational plagiocephaly., Methods: An institutional review board-approved retrospective study was conducted of all patients at the authors' clinic in whom deformational plagiocephaly was assessed using the Argenta classification system over a 6-year period; the patients underwent helmet therapy, and a minimum of 3 clinic visits were recorded. Inclusion criteria consisted of an Argenta Type II-V plagiocephalic deformity. Patients' conditions were categorized both by severity of the deformity and by patients' age at presentation. Statistical analysis was conducted using survival analysis., Results: There were 1050 patients included in the study. Patients with Type III, IV, and V plagiocephaly required progressively longer for deformity correction to be achieved than patients with Type II plagiocephaly (53%, 75%, and 81% longer, respectively [p < 0.0001]). This finding verified that the Argenta stratification indicated a progressive severity of deformity. No statistically significant difference in the time to correction was noted among the different age categories, which suggests that the previously held upper time limit for correction may be inaccurate. An overall correction rate to Type I plagiocephaly of 81.6% was achieved irrespective of severity and degree of the original deformity. This suggests that an inexpensive off-the-shelf molding helmet is highly effective and that expensive custom-fitted orthoses may not be necessary. The patients in the older age group (> 12 months) did not have a statistically significant longer interval to correction than the patients in the youngest age group (< 3 months). The mean length of follow-up was 6.3 months., Conclusions: Patients treated with passive helmet therapy in the older age group (> 12 months) had an improvement in skull shape within the same treatment interval as the patients in the younger age group (< 3 months). This study supports the use of passive helmet therapy for improvement in deformational plagiocephaly in infants from birth to 18 months of age and verifies the stratification of degree of deformity used in the Argenta classification system.

Objective: The objective of this study was to estimate the incidence of positional plagiocephaly in infants 7 to 12 weeks of age who attend the 2-month well-child clinic in Calgary, Alberta, Canada., Methods: A prospective cohort design was used to recruit 440 healthy full-term infants (born at ≥37 weeks of gestation) who presented at 2-month well-child clinics for public health nursing services (eg, immunization) in the city of Calgary, Alberta. The study was completed in 4 community health centers (CHCs) from July to September 2010. The CHCs were selected based on their location, each CHC representing 1 quadrant of the city. Argenta's (2004) plagiocephaly assessment tool was used to identify the presence or absence of plagiocephaly., Results: Of the 440 infants assessed, 205 were observed to have some form of plagiocephaly. The incidence of plagiocephaly in infants at 7 to 12 weeks of age was estimated to be 46.6%. Of all infants with plagiocephaly, 63.2% were affected on the right side and 78.3% had a mild form., Conclusions: To our knowledge, this is the first population-based study to investigate the incidence of positional plagiocephaly using 4 community-based data collection sites. Future studies are required to corroborate the findings of our study. Research is required to assess the incidence of plagiocephaly using Argenta's plagiocephaly assessment tool across more CHCs and to assess prevalence at different infant age groups. The utility of using Argenta's plagiocephaly assessment tool by public health nurses and/or family physicians needs to be established.

Background: The American Academy of Pediatrics Back to Sleep program in 1992 dramatically increased the incidence of posterior plagiocephaly in infants. In 2000, the craniofacial disorders program at Oregon Health & Science University established a plagiocephaly screening clinic staffed by pediatric nurse practitioners., Methods: Electronic medical records of patients seen in a single accredited craniofacial disorders clinic from 2005 to 2011 were reviewed retrospectively to identify patients screened independently by pediatric nurse practitioners for positional plagiocephaly versus synostosis., Results: Over a 7-year period, 1228 patients were independently screened. Over half [638 patients (52 percent)] were followed through subsequent visits for craniofacial disorders without any direct surgeon input. Of these, 169 (26 percent) were treated with orthotic consultation for a molding helmet, 385 (60 percent) received a combination of counseling and/or physical therapy for torticollis, and 84 (13 percent) were lost to follow-up. No patient managed by pediatric nurse practitioners was identified to have cranial synostosis and no patient underwent early or delayed surgery. All returning patients [n=554 (86 percent)] showed improvement in, or resolution of, their presenting deformity. The remaining 590 patients (48 percent) were referred by the pediatric nurse practitioner for surgical consultation. Computed tomographic imaging revealed synostosis in 121 patients., Conclusions: Pediatric nurse practitioners accurately screened over half of patients referred to a high-volume craniofacial disorders program for positional plagiocephaly versus synostosis, without surgeon input. Based on available information, no synostosis diagnosis was overlooked using this approach. With specific training, pediatric nurse practitioners working in a craniofacial disorders program can safely and independently screen for positional versus synostotic plagiocephaly., Clinical Question/level of Evidence: Diagnostic, III.