Does my child have a “ flat ” head?

1. Does my child have a “flat” head? Lloyd Ellis & Anna Noisette The Royal Children’s Hospital, Melbourne

2. Objectives of today’s session; • Types of cranial asymmetry • Identification of torticollis types • Prevention • Monitoring change • RCH model • Helmet therapy • Resources/Questions • Future?

3. The Skull

4. Craniosynotosis

5. Scaphocephaly

6. Scaphocephaly

7. Scaphocephaly

8. Trigonocephaly

9. Does my child have a “flat” head?

12. What causes deformational Plagiocephaly? • Prolonged pressure the skull in a particular position • SIDS protocols “Back to sleep” • Torticollis – a tightening of the neck muscles • Macrocephaly • Child resistant to ‘tummy time’ / muscle weakness • Lack of education of prevention methods • Utero constraints eg multiple births, insufficient pelvis • The expanding brain applies an externally directed force, with the brain capable of extreme plastic deformation with no loss of function or intellect if volume is not reduced

13. Sleeping Position • 1992 AAP recommended infants sleep supine/side to reduce SIDS risk • Revised 1996 – no sidelying sleeping • Victorian statistics: 1989 513 SIDs deaths/year 2000 140 SIDS deaths/year

14. Incidence • SIDS reduced significantly since inception of ‘Back to Sleep’ campaign (up to 40%) (Task Force on Sudden Infant Death Syndrome, 2005; Saeed et al., 2008; Xia et al., 2008; Losee & Mason, 2005). • Dramatic increase (10-48%) in incidence of plagiocephaly since “Back to Sleep” campaign (Saeed et al., 2008; Habal et al., 2004; Persing et al., 2003; Xia et al., 2008). • 13-15% singletons have some flattening • Right side more common • 1.3% incidence torticollis • Deformity persists in 30% at 2 years

15. Risk factors:found repeatedly • Male • First born • Multiple pregnancy • Prematurity • Oligohydramnios • Supine sleeping • < 5 mins tummy time/day • Delayed motor milestones • Preferred head orientation for sleep at 6 weeks • Positioning to same side for all bottle feeds

16. Decreased Prone Play • Decreased awareness of the importance of supervised ‘tummy time’, extended time on back • WHY? • Parental fears • Infant intolerance

17. Treatment of Plagiocephaly • Wait and See! • If torticollis present, treat with physiotherapy/gentle stretching • Counter positioning • Changing the forces on the head by altering the lying position • Cranio-reshaping helmet therapy • Fitting a custom made helmet which is worn for 23/34 hours a day until improved cosmesis is achieved

18. Classifications • Macdonald 1969 gave 3 classifications: • Sternomastoid tumour group (42.7%) • palpable mass present • Muscular torticollis group (30.6%) • tight SCM but no palpable mass • Reduced active/passive ROM • Postural torticollis group (22.1%) • no palpable mass or tightness • Full active/passive ROMCheng 2000

19. Congenital Muscular Torticollis (CMT) • CMT usually presenting with unilateral tightness of the sternocleidomastoid (SCM) muscle (Luther, 2002) • Characterised by lateral flexion to the affected side and rotation away from the affected side

20. Physiotherapy Rx • Goals of Physiotherapy: • increase PROM • increase AROM • Improving facial and cranial symmetry • Encourage gross motor development • Education, Stretching, Counter positioning techniques including positions carrying and for play

21. Counter Positioning • Parent education • Active and consistent repositioning of infant during play to apply pressure to prominent part of the skull • Use of passive devices to position baby, specially designed devices

22. Counter positioning Positioning, play and carrying techniques to encourage movement to ‘neglected side’ and lengthen tight muscles

23. Variety of positions for play • Supervised ‘tummy time’ whilst the infant is awake • Head shape and motor development are affected by sleep and awake positions of infant

24. Prevention is the key !

25. Key Preventative Strategies • Early detection of torticollis & referral to Physiotherapy • Encourage prone & side-lying during supervised awake play periods several times per day • Nightly/weekly alternating head positioning during supine sleeping • Avoid prolonged repetitive positioning (e.g. Car seat carriers, buggies, baby swings & bouncers. • Regularly change position of cot in room or toys/mobiles around cot. • Counter positioning / alternating the orientation of infant in the cot • Alternating feeding positions. (Saeed et al., 2008; Task Force on Sudden Infant Death Syndrome, 2005; Neufeld & Birkett, 1999; Persing et al., 2003; van Vlimmerman et al., 2008., Canadian Paediatric Society, 2001).

26. Assessment • History • Examination • Severity scoring • Measurement • Closure of anterior fontanelle • Range 4 to 18m

27. Clinical Severity Score

29. RCH treatment model • Research into the effectiveness of conservative management is just beginning • 3d Capture • Counterpositioning: initial treatment • Follow-up 3d review • Physiotherapy: if torticollis present • Orthotic management: for severe cases in older infants (from 6/12 old)

30. To treat or not to treat? • Cosmetic condition • Studies have shown that helmets improve the head shape • No study has been conducted to see if the condition self corrects regardless of treatment • Who should we treat ? • Last resort when conservative management fails. They are not an ‘easy’ option • Significant time and resource costs for health services and families

31. Indications for referral to RCH Deformational Plagiocephaly Clinic • Failure of early treatment strategies • Severe deformity • Severe torticollis and restriction • Associated medical conditions • Prematurity • Developmental delay

32. Helmet Therapy • Do not affect the growing brain • Not the easy option! • They are a significant cost in time and resources for families • For most children they shouldn’t be required

33. RCH treatment protocol: • To qualify a child must: • Have a deformational score of 6 or greater on the assessment sheet or • Score a 3 in a single deformation change • Be at least 6 months old • Have no craniosynostosis • Helmets do not treat torticollis!

34. How does it work?

35. Wearing Regime • Helmet is worn in gradually over 3-7 days (day time only), then worn 23/24 for duration of treatment • Review every 4-6 weeks according to growth • Repeating 3D photos mid treatment and end of treatment

36. The Finished product

37. The process • 3D photography using 5 point camera • Use to manufature helmet • Baseline to see shape improvement

38. Helmet Therapy

39. Helmet Therapy

40. Helmet Therapy

41. Helmet Therapy

42. Helmet Therapy

43. Helmet Therapy

44. Helmet Therapy

45. Helmet Therapy

46. Helmet Therapy

47. Positional Therapy

48. Positional Therapy

49. Positional Therapy

50. Positional Therapy 7mths 8.5mths