Article

Positional plagiocephaly

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Abstract

Cranial asymmetry occurring as a result of forces that deform skull shape in the supine position is known as deformational plagiocephaly. The risk of plagiocephaly may be modified by positioning the baby on alternate days with the head to the right or the left side, and by increasing time spent in the prone position during awake periods. When deformational plagiocephaly is already present, physiotherapy (including positioning equivalent to the preventive positioning, and exercises as needed for torticollis and positional preference) has been shown to be superior to counselling about preventive positioning only. Helmet therapy (moulding therapy) to reduce skull asymmetry has some drawbacks: it is expensive, significantly inconvenient due to the long hours of use per day and associated with skin complications. There is evidence that helmet therapy may increase the initial rate of improvement of asymmetry, but there is no evidence that it improves the final outcome for patients with moderate or severe plagiocephaly.

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... Recovery is possible within 2 years after birth. Accordingly, the incidence rates of PP are approximately 6.8 and 3.3 % at 12 months and 2 years of age, respectively [8]. ...
... In fact, babies who sleep on their stomachs reach gross motor development milestones noticeably earlier than babies who sleep on their backs, and infants who spent more than once per day in a prone position scored significantly higher in motor function than those who were seldom in a prone position. These advantages are most evident at 6 months of age and can persist beyond 18 months of age [8,12,18]. Therefore, motor delay in infants with PP may also be associated with an increase in supine sleeping. Given the negative impact of supine positioning on infant PP and neurodevelopment, many scholars have put forth parenting advice of Bsupine to sleep, prone to play,û rging parents to increase the amount of time infants spend on their stomach when they are awake to promote normal head morphology and motor development. ...
... Given the negative impact of supine positioning on infant PP and neurodevelopment, many scholars have put forth parenting advice of Bsupine to sleep, prone to play,û rging parents to increase the amount of time infants spend on their stomach when they are awake to promote normal head morphology and motor development. The Canadian Pediatric Society suggests placing infants in a prone position during awake time (tummy time) for 10 to 15 min at least three times per day [8]. ...
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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.
... The prevalence of PDP decreases with age, being as low as 3.3% at 2 years of life (Bialocerkowski et al. 2008). This observation suggests that the skull shape naturally changes within the first 2 years of life and is able to compensate the positional deformation, often resolving spontaneously and completely the clinical picture within the school age, at least in less severe cases (Cummings 2011;Hutchison et al. 2011). Accordingly, the evidence of the natural history of PDP would be in favor of a spontaneous improvement. ...
... For the second purpose, in particular, the rest or the sleep inside seat car should be avoided as well as any other factors affecting the baby' movements (too small crib, uncomfortable clots, etc.). According to the Canadian Task Force on Preventive Health Care, the following main rules should be observed for the prevention (Cummings 2011): (1) The first step is to reposition the head to encourage lying on each side in the supine position. Particular care should be taken for the babies with a strong positional preference to lie more on the opposite side of the head (Level II-2, Grade A). (2) Tummy time for 10-15 minutes at least 3 times per day should be encouraged because it significantly decreases the risk of PDP (Level II-2, Grade A). ...
... The incidence of this deformity is estimated to have increased from 0.3% to 8.2% or even higher today, depending on the sensitivity of the criteria used for diagnosing it (4). Factors increasing the risk of PP are male sex, firstborn, limited passive neck rotation at birth (congenital torticollis), multiple births, breech births, low birth weight, supine sleeping position at birth and at six weeks, bottle feeding, breast feeding fewer than three times per day, and lower activity level with slower achievement of milestones (6,7). Sleeping with the head to the same side and positional preference when sleeping are also associated with the development of PP (6). ...
... Factors increasing the risk of PP are male sex, firstborn, limited passive neck rotation at birth (congenital torticollis), multiple births, breech births, low birth weight, supine sleeping position at birth and at six weeks, bottle feeding, breast feeding fewer than three times per day, and lower activity level with slower achievement of milestones (6,7). Sleeping with the head to the same side and positional preference when sleeping are also associated with the development of PP (6). The side of occipital flattening correlates strongly to the side that the head faces when in the supine sleep position (8). ...
Article
Since the advent of recommendations for placing infants in the supine position during sleep to reduce the incidence of sudden infant death syndrome, clinicians have noted an increase in the frequency of cranial asymmetry due to deformation of suture sections of the infants’ skulls as a result of constant concentrated stress in one area at the back of their head. This specific form of cranial deformation is known as positional plagiocephaly and its rate of occurrence has increased from 0.3% in 8.2% within the past 30 years. Current treatments and methodologies for preventing and correcting positional plagiocephaly such as stretching exercises, bedding pillows, and cranial molding are not optimized for effectiveness and comfort. Literature surrounding the implementation of these methodologies or devices often assesses the relative effectiveness of each treatment through statistical means, or studies complications associated with their use. There is a lack of quantified mechanical analysis for determining the effectiveness of each treatment or engineered solutions. In this study, a finite element model was created and validated to study the effect of wearing a cranial helmet, as the most effective non-surgical device for treatment of positional plagiocephaly, on reducing concentrated stress from the back of the baby’s head during sleep. The results from this model were then compared to two other finite element models with a healthy baby sleeping in supine position on a pillow, and a patient diagnosed with a severe case of positional plagiocephaly sleeping on the flat side of his head in supine position. The geometries representing the head of the babies in these models are the refined 3D laser-scanned file of a patient’s head contour at Hanger Clinic as well as the cavity inside the cranial helmet that was used for treatment of the baby. After successfully assigning section and contact properties to different regions of the models, applying proper loading and boundary conditions, and performing mesh convergence studies for each of the three models, the average Von Mises stress values of each of the 13 different suture segments of each model were summarized in tables and evaluated using mathematical and qualitative methods. The stress value data obtained from different suture regions of the model with the cranial helmet resulted in the smallest standard deviation among all three populations which supports that wearing the cranial helmet helps to reduce stress concentrations. Use of the cranial helmet during sleep also showed a significant decrease of the average Von Mises stress within the posterior fontanelle by 90% compared to the healthy baby sleeping in supine position and 73.4% compared to the deformed head sleeping on the flat surface of the head. The major limitations of this study are correlated with the simplifying assumptions and geometries in generating and validating the models. Future studies need to focus on overcoming these limitations and generating more complex models using a similar approach. The methods used in this study and the results obtained from the models can serve as a basis for future development of engineered solutions that are more effective than the existing solutions in the market and reduce the side-effects and complications associated with their use.
... Tummy time has been recommended by researchers to prevent head deformity, strengthen trunk and neck muscles, and promote motor development among infants. 39,40 However, studies of tummy time practice and the relationship with health literacy are limited. Only one study, Yin et al., 12 assessed the relationship between parental health literacy and tummy time by asking for actual tummy time adherence; 66% of parents did not meet the current tummy time recommendation (at least 30 minutes per day) and a caregiver's low health literacy significantly increased the odds of a parent's reporting inadequate tummy time. ...
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Objective: To explore the association of maternal health literacy (MHL), parenting self-efficacy and early parenting practices among low-income mothers with infants. Design: A cross-sectional, descriptive correlational design. Participants: Low-income mothers (N=186) with infants. Methods: Face-to-face interviews were conducted using English and Spanish versions of questionnaires by trained bilingual research assistants. The Newest Vital Sign (NVS) screening tool was used to measure MHL. Results: Nearly three-quarters (72%) of mothers were rated as having low MHL. In the bivariate analysis, MHL was positively correlated with education, household income, language, social support, parenting self-efficacy, and early parenting practices, but negatively correlated with number of children. The study findings demonstrate that parenting self-efficacy had a mediating effect on MHL and early parenting practices among mothers with infants. Conclusion: Results suggest that future research is needed to advance MHL in low-income mothers and to inform potential HL interventions for this target population.
Article
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Positional plagiocephaly has garnered increased research interest since the introduction of the Back to Sleep campaign in the 1990s, and the subsequent increase in infants with cranial deformity. Research has focused on treatment outcomes and developing new modalities to address asymmetric heads. Little attention has been given to the cost of treatment and diagnosis. This study aimed to summarize the literature and provide an overview of the costs associated with a diagnosis of positional plagiocephaly. Methods: A literature review was performed by searching PubMed and Ovid Embase to identify studies pertaining to the "cost" of plagiocephaly diagnosis or treatment through direct financial factors, disturbance to daily routines (ie, through treatment prolongation), or related stress. Results: Twenty-nine peer-reviewed studies were included. Treatment options for plagiocephaly are stratified by severity and age of diagnosis, with different pathways available to treat different stages of asymmetry. The common factor across all treatment modalities is that earlier diagnosis unequivocally leads to better aesthetic outcomes and shorter treatment times. This leads to lower costs for treatment, a lower stress burden for parents, and lower costs for the healthcare system in the future through reduction of long-term effects. Our theoretical cost model suggests that early diagnosis at 4 months can lead to a treatment cost of $1495, when compared with $5195 for detection of deformity at or after 6 months. Conclusion: The dramatic cost disparity between early and late diagnosis highlights the need for reliable methods to accurately detect cranial deformity early in an infant's life.
Article
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Objective: To compare cranial helmet therapy (CHT) and physiotherapy (PT) for the effective treatment of positional plagiocephaly in infants in terms of improving functional recovery. Methods: This was a prospective cohort study involving 48 infants between 5–10 months of age with cranial deformities. The Cranial Vault Asymmetry Index (CVAI) and the Brunet–Lezine scale were calculated at the initiation of the study and after 40 treatment sessions. Results: The infants’ first assessment showed a delay in overall development areas with a global developmental quotient (DQ) (posture, coordination, sociability, and language) of 80.15. Although developmental improvements were observed in both groups in the Brunet–Lezine scale after treatment, the MANCOVA test showed no significant differences (F(5) = 0.82, p = 0.506, eta2 = 0.09). The CVAI reduced to 4.07% during the final evaluation in the cranial helmet group and 5.85% in the physiotherapy group without any significant differences between the two therapies (p = 0.70). Conclusions: No statistically significant differences were found between CHT and PT. After treatment, improvements from baseline measurements were observed in each of the readings of cranial deformity.
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Objectif: Décrire le processus et les données probantes ayant servi à mettre à jour les recommandations en matière de soins préventifs du RPR 2017 afin d’aider les professionnels de soins de première ligne à prendre les décisions sur les manœuvres à prioriser et à mettre en application dans la pratique. QUALITÉ DES DONNÉES: Nous avons effectué une recherche des publications médicales entre juin 2013 et juin 2016 en ayant recours à la méthodologie GRADE (Grading of Recommendations Assessment, Development and Evaluation) pour évaluer rigoureusement les principales études de recherche, et en présence d’un appui substantiel dans les nouvelles publications, nous avons modifié les recommandations. Message principal: Les changements importants des recommandations en matière de soins préventifs pour les enfants de 5 ans et moins sont l’ajout de la surveillance de l’indice de masse corporelle à compter de 2 ans; des données probantes plus robustes étayant l’introduction d’aliments allergènes sans délai (changement de la qualité de la recommandation de passable à bonne); la recommandation de poser aux parents des questions validées sur les effets de la pauvreté, des données probantes montrant qu’il n’existe aucun niveau sécuritaire d’exposition des enfants au plomb; une recommandation en matière de durée quotidienne du sommeil; la qualité de la recommandation est passée de passable à bonne pour les éléments liés à la prévention et au dépistage des expériences défavorables durant l’enfance, y compris l’évaluation des ecchymoses chez les bébés de moins de 9 mois; et la surveillance de la tension artérielle exclusivement chez les enfants à risque. Conclusion: Les expositions et les habitudes durant la petite enfance ont des conséquences sur la santé à court et à long terme. Le RPR continue de publier des mises à jour pour veiller à ce que les professionnels de la santé soient équipés pour favoriser la santé et le bien-être tout au long de la vie par l’entremise de soins éclairés par des données probantes aux jeunes enfants.
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Objective: To describe the process and evidence used to update preventive care recommendations in the 2017 Rourke Baby Record to assist primary care providers' decisions around which maneuvers to prioritize and implement in practice. Quality of evidence: A search of the literature from June 2013 to June 2016 was conducted, using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodology to critically appraise primary research studies, and recommendations were changed where there was substantial support from the new literature. Main message: The important changes in preventive care recommendations for children up to 5 years of age include the addition of body mass index monitoring as of 2 years of age; stronger evidence to support the introduction of allergenic foods without delay (strength of recommendation change from fair to good); the recommendation to ask validated questions regarding the effects of poverty; evidence showing no safe level of lead exposure in children; the recommendation of a daily sleep duration; the upgrade of recommendation strength from fair to good of items related to the prevention and detection of adverse childhood experiences, including assessment of bruising in babies younger than 9 months; and blood pressure monitoring only for children at risk. Conclusion: Early childhood exposures and habits have short- and long-term health consequences. The Rourke Baby Record will continue to publish updates to ensure that primary care providers are equipped to promote lifelong health and well-being through evidence-informed care in young children.
Article
Objective: To investigate the efficacy of 2-month course of sleeping position correction in the treatment of positional plagiocephaly in infants aged <8 months. Methods: A total of 73 infants with positional plagiocephaly between January 2015 and June 2016 were divided into treatment group (n=46) and control group (n=27) according to parents' wishes. The treatment group received sleeping position correction, while the control group received sleep curve mattress. The oblique diameters A and B in the two groups were measured and the cranial vault asymmetry (CVA) was calculated before and after treatment. The severity of positional plagiocephaly based on CVA was compared between the two groups before and after treatment. The Gesell Developmental Scale was used to determine the developmental quotients (DQs) in the motor, adaptive, language, and social domains in the two groups before and after treatment. Results: Before treatment, there were no significant differences in oblique diameters A and B, CVA, and DQs in the four specific domains between the two groups (P>0.05). After 2 months of treatment, the treatment group had a significantly greater oblique diameter B and a significantly smaller CVA than the control group (P<0.05); there were no significant differences in DQs in the four specific domains between the two groups (P>0.05). After treatment, both groups had significant improvements in oblique diameters A and B, CVA, and DQs in the motor and adaptive domains (P<0.01); moreover, the treatment group showed a significant improvement in the DQs in the social domain (P<0.01). There was no significant difference in the severity of positional plagiocephaly between the two groups before and after treatment (P>0.05). Conclusions: For infants with positional plagiocephaly, sleeping position correction has better efficacy and is more convenient and economical than the sleep curve mattress, so it holds promise for clinical application.
Article
Many centres report receiving more referrals for deformational plagiocephaly since implementation of the Back to Sleep campaign. This commentary combines clinical experience, local quality improvement data and existing literature to highlight three points to help prevent and manage plagiocephaly: (1) communicating ‘Back to Sleep, Tummy to Play’, (2) the importance of early detection and (3) plagiocephaly as a marker of developmental risk. We recommend: (1) equal emphasis on the messages of Back to Sleep and supervised Tummy to Play, to start this messaging early and reinforce at every opportunity; (2) examination of skull shape and neck range of motion as a routine component of the newborn assessment so that caregivers can implement positioning and handling suggestions immediately and (3) physiotherapy referral for babies who have torticollis, or who show persistent or worsening plagiocephaly despite positioning and handling interventions, for further assessment and management.
Chapter
The cranial vault or neurocranium encloses the brain, meninges, and cerebrospinal fluid. The single most important stimulus for head growth during infancy and childhood is brain growth, and this will be a recurrent theme when trying to consider the driving forces behind many neurosurgical or central nervous system-related findings in your young patients. In the subsequent chapters, we will systematically introduce some pathologic conditions pertaining to the intersection of brain and skull development throughout adolescence. The abnormally large head, small head, and misshapen heads are all of concern to parents and medical care providers alike. In this chapter we will introduce a framework of thinking to use as a reference tool when evaluating your patients. In the subsequent chapter, we will provide a simple and yet comprehensive framework for the pediatric neurologic examination and then begin our journey through the various manifestations of normal, gone awry.
Chapter
Positional plagiocephaly typically consists of right or left occipital flattening which may be self-perpetuating, in that once it occurs, it may be increasingly difficult for the infant to turn and sleep on the other side. This position causes the baby’s very malleable head to lie repeatedly on the same area of the occipital bone, determining or worsening the flattening. The pathogenetic mechanism seems to recognize its origin in the gravitational force acting at the contact point between the skull of the newborn and the rigid surface of the support. Among the risk factors for posterior occipital plagiocephaly, several maternal, perinatal, and postnatal factors are recognized. The major cause of posterior positional plagiocephaly, however, is believed to be the supine position held for a long time by the infant after birth, during sleep and when awake. Posterior positional plagiocephaly is often associated with postural torticollis which further exacerbates its extent and complicates its course. It is hoped that increasing the awareness of identified risk factors and early implementation of good practices will reduce the development of deformational plagiocephaly.
Chapter
Cranial deformities have always existed, but it is only until recently that they provoked a greater interest. Several reports have demonstrated an increasing tendency for occipital plagiocephaly since 1992. The incidence of positional plagiocephaly varies according to the diagnostic criteria used. The increased incidence of positional occipital plagiocephaly is most likely related to the recommendations given by the American Pediatrics Association to put the infants to sleep on their backs. In 1992 it had, in fact, started the campaign “Back to Sleep” which provided that all healthy children born at term were placed to sleep on their backs to prevent sudden infant death syndrome. The simultaneous diffusion of principal multifunction devices for the transport of infants did increase the time that the child spends with the occipital region under constant pressure also when awake.
Article
Background - In the last fifteen years, numerous publications have reported the increase in the incidence of positional occipital plagiocephaly (POP) in babies since the recommendation of the supine position for sleep in the first months of life was introduced to reduce the risk of Sudden Infant Death Syndrome (SIDS). On the contrary, there are few studies on the outcome of the cranial asymmetry in later childhood and none have been published on the follow-up of Italian babies presenting with the problem. Objectives - To investigate 1) the outcome in early childhood of the head shape in young babies presenting with POP in the first months of life and 2) eventual correlation of motor and/or language development problems. Methods - The clinical history of the 314 babies enrolled in the study was examined. Questionnaires enquiring into the parents' evaluation of their children's head shape and information on their motor and language milestones were distributed to the 232 couples of parents who agreed to participate in the study. Results - The data from the clinical notes confirmed the characteristics typical of babies who develop POP already described in literature. 199 parents returned the questionnaires; the average age of their children was 4.8 years (range 3.3 to 6.7 years). 87.5% of the parents considered the cosmetic appearance of their children's head shape to be normal, whereas 30.2% reported a residual cranial asymmetry on palpation. 100% referred normal motor development but 34.4% reported some problems in language development. Conclusions - This study confirms the other data available in that POP can be considered mainly a cosmetic problem, which presents in the first months of life and greatly improves spontaneously during early childhood. Further studies need to investigate the relationship between outcome in childhood and treatments undergone in the first year of life.
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Molding helmet therapy is a widely accepted treatment for positional plagiocephaly that is generally considered to be low risk. Multiple large outcome studies have shown good results, but adverse events are rarely reported. The literature on helmet therapy was reviewed to clarify the clinical experience with associated complications. Although significant complications were extremely rare, there was a large degree of variability in detection of lesser problems such as minor skin irritation. Patients with a primarily brachycephalic morphology may be at higher risk for poorly fitting orthoses. Most reported complications are minor and self-limited. Maintenance of good helmet hygiene appears to be the most effective strategy for reducing or eliminating complications.
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To evaluate and summarize the evidence comparing nonsurgical therapies in the treatment of infants with deformational plagiocephaly. Scientific articles and abstracts published in English between January 1978 and August 2007 were searched from 5 online literature databases, along with a manual search of conference proceedings. Studies were selected and appraised for methodological quality by 2 reviewers independently using a Critical Appraisal Skills Programme form (cohort criteria). Molding helmet therapy vs head repositioning therapy. Success rate of the treatment. A total of 3793 references were retrieved. There were no randomized controlled trials. Only 7 cohort studies met the inclusion criteria. Five of the 7 studies presented evidence that molding therapy is more effective than repositioning, even with the biases favoring the repositioning groups. In the molding groups, the asymmetry was more severe and the infants were older. The infants who failed to respond to repositioning therapy were also switched to molding therapy. The treatment outcomes from the other 2 studies were difficult to assess because of flaws in their study design. Finally, the relative improvement of using molding therapy was calculated from one study. It was about 1.3 times greater than with repositioning therapy. The studies showed considerable evidence that molding therapy may reduce skull asymmetry more effectively than repositioning therapy. However, definitive conclusions on the relative effectiveness of these treatments were tempered by potential biases in these studies. Further research is warranted.
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To study the effect of pediatric physical therapy on positional preference and deformational plagiocephaly. Randomized controlled trial. Bernhoven Hospital, Veghel, the Netherlands. Of 380 infants referred to the examiners at age 7 weeks, 68 (17.9%) met criteria for positional preference, and 65 (17.1%) were enrolled and followed up at ages 6 and 12 months. Infants with positional preference were randomly assigned to receive either physical therapy (n = 33) or usual care (n = 32). The primary outcome was severe deformational plagiocephaly assessed by plagiocephalometry. The secondary outcomes were positional preference, motor development, and cervical passive range of motion. Both groups were comparable at baseline. In the intervention group, the risk for severe deformational plagiocephaly was reduced by 46% at age 6 months (relative risk, 0.54; 95% confidence interval, 0.30-0.98) and 57% at age 12 months (0.43; 0.22-0.85). The numbers of infants with positional preference needed to treat were 3.85 and 3.13 at ages 6 and 12 months, respectively. No infant demonstrated positional preference at follow-up. Motor development was not significantly different between the intervention and usual care groups. Cervical passive range of motion was within the normal range at baseline and at follow-up. When infants were aged 6 months, parents in the intervention group demonstrated significantly more symmetry and less left orientation in nursing, positioning, and handling. A 4-month standardized pediatric physical therapy program to treat positional preference significantly reduced the prevalence of severe deformational plagiocephaly compared with usual care. isrctn.org Identifier: ISRCTN84132771.
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To assist women and their physicians in making decisions regarding the prevention of breast cancer with tamoxifen and raloxifene. Systematic review of English-language literature published from 1966 to August 2000 retrieved from MEDLINE, HealthSTAR, Current Contents and Cochrane Library. The strength of evidence was evaluated using the methods of the Canadian Task Force on Preventive Health Care and the Steering Committee on Clinical Practice Guidelines for the Care and Treatment of Breast Cancer. Women at low or normal risk of breast cancer (Gail risk assessment index < 1.66% at 5 years): There is fair evidence to recommend against the use of tamoxifen to reduce the risk of breast cancer in women at low or normal risk of the disease (grade D recommendation). Women at higher risk of breast cancer (Gail index > or = 1.66% at 5 years): Evidence supports counselling women at high risk on the potential benefits and harms of breast cancer prevention with tamoxifen (grade B recommendation). The cutoff for defining high risk is arbitrary, but the National Surgical Adjuvant Breast and Bowel Project P-1 Study included women with a 5-year projected risk of at least 1.66% according to the Gail index, and the average risk of patients entered in the trial was 3.2%. Examples of high-risk clinical situations are 2 first-degree relatives with breast cancer, a history of lobular carcinoma in situ or a history of atypical hyperplasia. As the risk of breast cancer increases above 5% and the benefits outweigh the harms, a woman may choose to take tamoxifen. The duration of tamoxifen use in such situations is 5 years based on the results from trials of tamoxifen involving women with early breast cancer. If a woman raises concerns or has already been evaluated and is calculated to be at high risk, then individuals experienced and skilled in counselling may discuss the potential benefits and harms of tamoxifen use. Important additional issues: Prevention of breast cancer with raloxifene: Current evidence does not support recommending chemoprevention of breast cancer with raloxifene outside of a clinical trial setting. Screening using the Gail risk assessment index: This index was the main eligibility criterion for enrolling women in the one study that showed potential benefit from chemoprevention. However, it has not been evaluated for use as a routine screening or case-finding instrument; validation of the index is required. Overall, current evidence does not support a shift to its routine use in physicians' offices for screening or case finding. However, when a woman or her physician is concerned about the woman's increased risk of breast cancer, the index can be a useful tool in deciding whether to pursue an in-depth discussion of the potential benefits and harms of chemoprevention. Hence, the approach to identifying women at higher risk who warrant counselling and shared decision-making will vary across practices. (The risk assessment index is available online at http://bcra.nci.nih.gov/brc/). [A patient version of these guidelines appears in Appendix 2.] The authors' original text was revised by both the Canadian Task Force on Preventive Health Care and the Steering Committee on Clinical Practice Guidelines for the Care and Treatment of Breast Cancer. The final document reflects a consensus of these contributors. Health Canada. COMPLETION DATE: February 2001.
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In this document, the Canadian Task Force on Preventive Health Care (CTFPHC) updates its earlier breast-feeding recommendations1 by presenting evidence on interventions that improve the initiation or duration of breast-feeding (or both). Breast-feeding has been shown in both developing and developed countries to improve the health of infants and their mothers, making it the optimal method of infant nutrition.2,3 Although the prevalence of breast-feeding in Canada has risen, with over three-quarters of mothers now initiating breast-feeding, the duration of this practice remains short of the recommended World Health Organization (WHO) targets of exclusive breast-feeding for 6 months and partial breast-feeding for up to 2 years.4,5 Recent Canadian data indicate that 22% of recent mothers aged 15–49 years breast-feed for less than 3 months, and 35% do so for at least 3 months.6 This premature discontinuation is more a result of difficulty with breast-feeding, including lack of information and support, than of women's choice.7 In fact, the number of Canadian hospitals that would qualify as “baby-friendly” according to WHO–UNICEF criteria8 was 5 of 523 hospitals responding to a 1993 survey,9 and according to UNICEF only a single hospital had that designation in 2002.10
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Although referrals for nonsynostotic plagiocephaly (NSP) have increased in recent years, the prevalence, natural history, and determinants of the condition have been unclear. The objective of this study was to assess the prevalence and natural history of NSP in normal infants in the first 2 years of life and to identify factors that may contribute to the development of NSP. Two hundred infants were recruited at birth. At 6 weeks, 4 months, 8 months, 12 months, and 2 years, the head circumference shape was digitally photographed, and head shape was quantified using custom-written software. At each age, infants were classified as cases when the cephalic index was > or =93% and/or the oblique cranial length ratio was > or =106%. Neck rotation and a range of infant, infant care, socioeconomic, and obstetric factors were assessed. Ninety-six percent of infants were followed to 12 months, and 90.5% were followed to 2 years. Prevalence of plagiocephaly and/or brachycephaly at 6 weeks and 4, 8, 12, and 24 months was 16.0%, 19.7%, 9.2%, 6.8%, and 3.3% respectively. The mean cephalic index by 2 years was 81.6% (range: 72.0%-102.6%); the mean oblique cranial length ratio was 102.6% (range: 100.1%-109.4%). Significant univariate risk factors of NSP at 6 weeks include limited passive neck rotation at birth, preferential head orientation, supine sleep position, and head position not varied when put to sleep. At 4 months, risk factors were male gender, firstborn, limited passive neck rotation at birth, limited active head rotation at 4 months, supine sleeping at birth and 6 weeks, lower activity level, and trying unsuccessfully to vary the head position when putting the infant down to sleep. There is a wide range of head shapes in infants, and prevalence of NSP increases to 4 months but diminishes as infants grow older. The majority of cases will have resolved by 2 years of age. Limited head rotation, lower activity levels, and supine sleep position seem to be important determinants.
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We compare positioning with orthotic therapy in 298 consecutive infants referred for correction of head asymmetry. We evaluated 176 infants treated with repositioning, 159 treated with helmets, and 37 treated with initial repositioning followed by helmet therapy when treatment failed. We compared reductions in diagonal difference (RDD) between repositioning and cranial orthotic therapy. Helmets were routinely used for infants older than 6 months with DD >1 cm. For infants treated with repositioning at a mean age of 4.8 months, the mean RDD was 0.55 cm (from an initial mean DD of 1.05 cm). For infants treated with cranial orthotics at a mean age of 6.6 months, the mean RDD was 0.71 cm (from an initial mean DD of 1.13 cm). Infants treated with orthotics were older and required a longer length of treatment (4.2 vs 3.5 months). Infants treated with orthosis had a mean final DD closer to the DD in unaffected infants (0.3 +/- 0.1 cm), orthotic therapy was more effective than repositioning (61% decrease versus 52% decrease in DD), and early orthosis was significantly more effective than later orthosis (65% decrease versus 51% decrease in DD).
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The purpose of this work was to identify risk factors for deformational plagiocephaly within 48 hours of birth and at 7 weeks of age. This was a prospective cohort study in which 380 healthy neonates born at term in Bernhoven Hospital in Veghel were followed at birth and at 7 weeks of age. Data regarding obstetrics, sociodemographics, asymmetry of the skull, anthropometrics, motor development, positioning, and care factors related to potentially provoking deformational plagiocephaly were gathered, with special interest for putative risk factors. The main outcome measure at birth and at 7 weeks of age was deformational plagiocephaly, assessed using the plagiocephalometry parameter oblique diameter difference index, a ratio variable, calculated as the longest divided by the shortest oblique diameter of the skull x 100%. A cutoff point of > or = 104% was used to indicate severe deformational plagiocephaly. Only in 9 of 23 children who presented deformational plagiocephaly at birth was deformational plagiocephaly present at follow-up, whereas in 75 other children, deformational plagiocephaly developed between birth and follow-up. At birth, 3 of 14 putative risk factors were associated with severe flattening of the skull: gender, birth rank, and brachycephaly. At 7 weeks of age, 8 of 28 putative risk factors were associated with severe flattening: gender, birth rank, head position when sleeping, position on chest of drawers, method of feeding, positioning during bottle-feeding, and tummy time when awake. Early achievement of motor milestones was a protective factor for developing deformational plagiocephaly. Deformational plagiocephaly at birth was not a predictor for deformational plagiocephaly at 7 weeks of age. There was no significant relation between supine sleeping and deformational plagiocephaly. Three determinants were associated with an increased risk of deformational plagiocephaly at birth: male gender, first-born birth rank, and brachycephaly. Eight factors were associated with an increased risk of deformational plagiocephaly at 7 weeks of age: male gender, first-born birth rank, positional preference when sleeping, head to the same side on chest of drawers, only bottle feeding, positioning to the same side during bottle feeding, tummy time when awake < 3 times per day, and slow achievement of motor milestones. This study supports the hypothesis that specific nursing habits, as well as motor development and positional preference, are primarily associated with the development of deformational plagiocephaly. Earlier achievement of motor milestones probably protects the child from developing deformational plagiocephaly. Implementation of practices based on this new evidence of preventing and diminishing deformational plagiocephaly in child health care centers is very important.
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This review synthesized current research evidence on the prevalence, risk factors, and natural history of positional plagiocephaly. Research published between 1985 and 2007 was sourced from 13 databases. Evidence was categorized according to a hierarchy and rated on a standardized critical appraisal tool. These evaluations were incorporated into a narrative synthesis of the main results. Eighteen studies met inclusion criteria (prevalence: n=3, risk factors: n=17, natural history: n=1). The methodological quality of studies was fair. The point prevalence of positional plagiocephaly appears to be age-dependent and may be as high as 22.1% at 7 weeks of age. Point prevalence tends to decrease with age and may be as low as 3.3% at 2 years. When compared with historical data, the prevalence of positional plagiocephaly appears to have remained stable over the last four decades. Assisted delivery, first born child, male sex, cumulative exposure to the supine position, and neck problems may increase the risk of positional plagiocephaly. To reduce the risk of positional placiocephaly, infants should experience a variety of positions, other than supine, while they are awake and supervised, and early treatment may be warranted for infants with neck problems and/or strong head preference.
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The "Back to Sleep" campaign has dramatically decreased the incidence of sudden infant death syndrome; however, its sequelae of deformational plagiocephaly have today reached epidemic proportions. In the last decade, we have learned to distinguish deformational plagiocephaly clinically from craniosynostosis, thereby preventing its unnecessary surgical correction. Primary care providers must increasingly be aware of this condition and, in turn, educate new parents about its prevention. Should preventative measures fail and infants develop persistent sleep patterns that result in craniofacial deformities, deformational plagiocephaly can be treated successfully with behavior modification or cranial molding-helmet therapy.
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Plagiocephaly is a term derived from the Greek (plagios - "twisted'' and kephale - "head'') and describes an asymmetric head shape. The potential causes of cranial asymmetry are multiple and the most important aspect in assessing any child with plagiocephaly is the need to exclude the possibility of craniosynostosis. Craniosynostosis is the premature fusion of one or more skull sutures and often leads to altered head shape; there may also be an associated intracranial hypertension and developmental delay. Premature closure may occur in a single suture or in multiple sutures, as is more commonly seen in syndromic craniosynostotic conditions such as Crouzon or Apert syndromes. Treatment involves assessment, multidisciplinary input from psychologists and speech therapists, and surgery. Positional or deformational plagiocephaly usually presents as occipital flattening present in the peri- natal period, either as a unilateral or bilateral deformity and may be associated with changes to the anterior craniofacial skeleton.(1) The purpose of this article is to summarise current concepts in the management of positional plagiocephaly and to highlight the present controversy concerning management of the condition with helmet therapy.
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