Asymmetry in infancy : The effect of paediatric physical therapy on the course of deformational plagiocephaly and subsequent developmental delay

Abstract

Epidemiological studies have shown that prone and side sleeping is a major risk for Sudden Infant Death Syndrome. Since the early nineties, concurrent with the increase in supine sleeping, consistent with the American Academy of Pediatrics recommendations that healthy term infants should be positioned on their side or back to sleep, a rise in the prevalence of positional preference and deformational plagiocephaly has been observed. We presented a clinical flow chart showing different pathways in therapeutic strategies such as physical therapy, orthotic devices and surgery on the most occurring asymmetries in infancy (congenital muscular torticollis, positional torticollis and plagiocephaly) , based on best available evidence in current literature, in order to achieve uniformity in therapeutic thinking and performance. We investigated the psychometrical aspects of plagiocephalometry, a new instrument to assess and quantify the asymmetry of the skull. Using a thermoplastic material to mould the outline of the infant's skull, a reproduction of the skull shape is performed on paper allowing for accurate cephalometric measurements. We concluded that plagiocephalometry is an easy-to-apply, non-invasive, reliable and valid method to assess skull asymmetry with good clinical use and low application costs. Plagiocephalometry might serve as an instrument used in all levels of care for children with deformational plagiocephaly and might, by measurements over time, provide information concerning the natural course of deformational plagiocephaly as well as the assessment of the effects of conservative treatment strategies. We documented the prevalence of positional preference and deformational plagiocephaly at birth. We also studied prevalence changes over time until the age of seven weeks, and we identified risk factors that influence the occurrence and possible progression of deformational plagiocephaly. Three determinants were associated with an increased risk of deformational plagiocephaly at birth: male gender, birth rank first-born and brachycephaly. Deformational plagiocephaly at birth is not a predictor for deformational plagiocephaly at seven weeks of age. Deformational plagiocephaly at seven weeks of age was primarily caused by postnatal, external factors (nursing habits, positioning and care). Earlier achievement of motor milestones protects the child from developing deformational plagiocephaly. No significant association was found between supine sleeping and the development of positional preference and deformational plagiocephaly. A persistent restriction of the range of joint motion of the cervical spine associated with deformational plagiocephaly was not found. We investigated the effectiveness of a standardized paediatric physical therapy protocol on the occurrence and the course of positional preference and severe deformational plagiocephaly, assessed at seven weeks after birth (entry of the study) and at the age of six and twelve months. A four-month standardized paediatric physical therapy intervention program on children with positional preference significantly reduced the prevalence of severe deformational plagiocephaly compared to usual care. For children with deformational plagiocephaly and their parents, a careful multidisciplinary assessment and follow up program in child health care centres and paediatric physical therapy practices, based on updated protocols, clinical guidelines regarding positioning, handling and training of children with positional preference and with or without deformational plagiocephaly, are highly recommendable.