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The moulded baby syndrome: Incidence and risk factors regarding 1,001 neonates

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Postural deformities are frequent in neonates. The moulded baby syndrome (MBS) comprises one or more of the following disorders: plagiocephaly, torticollis, congenital scoliosis, pelvic obliquity, adduction contracture of a hip and/or malpositions of the knees or feet. We analysed the incidence of MBS in healthy neonates and identified the risk factors of its composing elements. One thousand and one healthy neonates were examined on the second or third day of life by the same paediatrician. Familial, obstetrical, perinatal history and putative risk factors for postural deformities were collected. Families of newborns with a torticollis or plagiocephaly were given positioning advice and the outcome was evaluated by a phone survey 2 months later. MBS was detected in 107 neonates (10.7%): 97 plagiocephalies or torticollis, 25 congenital scoliosis or pelvic obliquities, and 13 malpositions of the knees or feet. We identified risk factors related to the mother (age: OR=1.39, parity: OR=0.643), to the obstetrical history (preterm labour: OR=1.65, oligoamnios: OR=10.179, breech presentation: OR=2.746, pregnancy toxaemia: OR=3.773, instrumental delivery: OR=6.028) and to the newborn (male gender: OR=1.982, birth length: OR=1.196). The initial plagiocephaly or torticollis improved in 77% of infants after 2 months of stimulation and positioning measures. Paediatricians should be alert regarding the frequent but subtle MBS postural deformities and give positioning advice to the parents. A neonate of male gender or greater birth length, with an older primiparous mother, a history of preterm labour, oligoamnios or pregnancy toxaemia, a breech presentation or an assisted delivery is more likely to have MBS.
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ORIGINAL PAPER
The moulded baby syndrome: incidence and risk factors
regarding 1,001 neonates
Amandine S. Rubio &Jacques R. Griffet &Hervé Caci &
Etienne Bérard &Toni El Hayek &Patrick Boutté
Received: 17 April 2008 /Revised: 9 July 2008 / Accepted: 10 July 2008 / Published online: 16 September 2008
#Springer-Verlag 2008
Abstract Postural deformities are frequent in neonates.
The moulded baby syndrome (MBS) comprises one or
more of the following disorders: plagiocephaly, torticollis,
congenital scoliosis, pelvic obliquity, adduction contracture
of a hip and/or malpositions of the knees or feet. We
analysed the incidence of MBS in healthy neonates and
identified the risk factors of its composing elements. One
thousand and one healthy neonates were examined on the
second or third day of life by the same paediatrician.
Familial, obstetrical, perinatal history and putative risk
factors for postural deformities were collected. Families of
newborns with a torticollis or plagiocephaly were given
positioning advice and the outcome was evaluated by a
phone survey 2 months later. MBS was detected in 107
neonates (10.7%): 97 plagiocephalies or torticollis, 25
congenital scoliosis or pelvic obliquities, and 13 malposi-
tions of the knees or feet. We identified risk factors related
to the mother (age: OR=1.39, parity: OR =0.643), to the
Eur J Pediatr (2009) 168:605611
DOI 10.1007/s00431-008-0806-y
A. S. Rubio
Service de Pédiatrie, Hopital Archet 2, CHU de Nice,
151 St. Antoine de Ginestière,
06200 Nice, France
A. S. Rubio :H. Caci :P. Boutté
Department of Child and Adolescent Care,
University Hospital of Nice,
Nice, France
A. S. Rubio (*)
Department of Physiology,
University of Nice Sophia Antipolis,
Nice, France
e-mail: rubio.a@chu-nice.fr
J. R. Griffet
Department of Pediatric Orthopedic Surgery,
University Hospital of Nice, University of Nice Sophia Antipolis,
Nice, France
e-mail: griffet.j@chu-nice.fr
J. R. Griffet
Department of Pediatric Orthopedic Surgery,
University Hospital of Nice,
Nice, France
J. R. Griffet
Department of Pediatric Surgery,
University of Nice Sophia Antipolis,
Nice, France
E. Bérard
Department of Child and Adolescent Care,
University Hospital of Nice, University of Nice Sophia Antipolis,
Nice, France
E. Bérard
Department of Pediatric Nephrology,
University of Nice Sophia,
Nice, France
T. El Hayek
Department of Pediatric Orthopedic Surgery,
University Hospital of Nice,
Nice, France
T. El Hayek
Department of Pediatric Orthopedic Surgery,
University of Nice Sophia Antapolis,
Nice, France
P. Boutté
Department of Pediatrics,
University of Nice Sophia Antapolis,
Nice, France
obstetrical history (preterm labour: OR =1.65, oligoamnios:
OR=10.179, breech presentation: OR= 2.746, pregnancy
toxaemia: OR=3.773, instrumental delivery: OR= 6.028)
and to the newborn (male gender: OR =1.982, birth length:
OR=1.196). The initial plagiocephaly or torticollis im-
proved in 77% of infants after 2 months of stimulation and
positioning measures. Paediatricians should be alert regard-
ing the frequent but subtle MBS postural deformities and
give positioning advice to the parents. A neonate of male
gender or greater birth length, with an older primiparous
mother, a history of preterm labour, oligoamnios or
pregnancy toxaemia, a breech presentation or an assisted
delivery is more likely to have MBS.
Keywords TAC syndrome .Plagiocephaly .Torticollis .
Congenital scoliosis .Hip contracture
Abbreviations
MBS Moulded baby syndrome
OR Odds ratio
Introduction
During the neonatal examination in the maternity ward, the
paediatrician seeks malformations and other congenital
anomalies. A careful clinical review of the locomotor
apparatus is an important part of this examination, as it must
detect signs of obstetrical trauma, malformations and malpo-
sitions. Malpositions dues to a foetomaternal conflict with
excessive intrauterine constraints are referred to as the
moulded baby syndrome (MBS), first described by Lloyd-
Roberts and Pilcher in 1965 [18]. This syndrome, also named
by some authors the TAC syndrome [13] (turned head,
adducted hip, truncal curvature), comprises one or more of
the following disorders: head moulding (occipital or frontal
plagiocephaly), postural torticollis (turned or tilted head with
or without limited active or passive head rotation), congen-
ital scoliosis, pelvic obliquity with unilateral adduction
contracture of a hip joint eventually associated with hip
instability and malpositions of the knees or feet.
Identifying cephalic elements of the MBS (head mould-
ing and torticollis) was a special concern in this study.
Indeed, since the American Academy of Pediatrics (AAP)
recommended that infants be placed supine to sleep to
reduce the risk of sudden infant death syndrome in 1992
[1], posterior deformational plagiocephaly and torticollis
have become a very frequent complaint in paediatrics [15,
17,24]. Most torticollis or plagiocephalies are detected by
parents or paediatricians at around 2 to 3 months of age
[20], with mothers claiming that the head was round at birth
[8]. We nevertheless hypothesised that this plagiocephaly
was already present at birth or that there already existed a
positional torticollis, which would later worsen and lead to
a cranial flattening with the infant sleeping in his position
of comfort.Early detection at birth could lead to an early
treatment of these malpositions with simple positioning and
stimulation measures and possibly reduce the onset of
muscular torticollis.
This study aimed at detecting MBS in a large cohort of
healthy neonates, to depict its clinical patterns and to
analyse its risk factors in terms of mother-, obstetrics- and
neonate-dependent factors. We also explored whether
simple handling advice given to the parents of newborns
with a torticollis or plagiocephaly would lead to the
improvement of the deformity by the third month of life.
Materials and methods
The study was composed of 1,001 consecutive healthy
neonates born at the University Hospital of Nice who were
examined 36 to 72 h after delivery in the postnatal ward
over a 6-month period (May to November 2006). We
excluded very premature infants with a gestational age <32
weeks and infants who required prolonged treatment in the
intensive care unit. After obtaining informed consent from
the parents for participation, data were collected from the
medical records of the neonate and the mother, and from
parentsquestioning regarding sociodemographic factors
(mothers age, gestation, parity, parentsethnicity), obstet-
rical factors (multiple pregnancy, history of preterm labour,
oligo- or hydramnios, pregnancy toxaemia, foetus presen-
tation, mode of delivery, forceps or vacuum assistance) and
neonate characteristics (gestational age, gender, birth
measurements, medical or surgical anomalies).
Physical examination of the neonate noted cranial or
facial asymmetry, preferred head orientation or head tilt,
limitation in or resistance to gentle passive neck rotation,
truncal curvature, pelvic obliquity, unilateral or bilateral
contracture of a hip joint, and malpositions of the knees and
feet. All examinations were conducted by the same
paediatrician.
We considered that MBS consisted of three sets of
deformities depending on their location: the head and neck
segment with occipital or frontal plagiocephaly, head turning
or head tilt with or without limited passive head rotation range
(items referred to as MBS 1), congenital scoliosis, pelvic
obliquity, adduction contracture of a hip joint, limitation or
asymmetry of the hipsabduction, hip instability (MBS 2),
and malpositions of the knees (genu recurvatum) and feet
(talus valgus, metatarsus adductus) as MBS 3. Simple pes
supinatus and pes talus were not included in MBS as they are
extremely frequent and associated with physiological posi-
tioning of the foetus [17]. To appreciate its severity, a score
was given to the MBS of each neonate (ranging from 1 to
606 Eur J Pediatr (2009) 168:605611
14), with one point attributed to each of the elements listed
above. The score was sub-divided into MBS 1, MBS 2 and
MBS 3 scores.
Putative risk factors were divided into mother-dependent
factors (age and parity), obstetrical factors (multiple pregnan-
cy, premature labour, pregnancy toxaemia, oligoamnios,
foetal presentation at birth and instrumental delivery) and
child-dependent factors (gestational age, gender, ethnicity,
birth measurements and ponderal index P/T
3
).
If an infant had either plagiocephaly, head tilt or rotation,
the parents were given handling suggestions, encouraged to
change the infants position in the crib frequently in order
to position him away from the flattened area and to
stimulate the infant to obtain an active rotation in the
opposite direction from the position of comfort.Parents
were offered to be contacted by phone after 2 to 3 months
to evaluate the outcome of the plagiocephaly or torticollis.
They were then submitted a survey regarding their childs
spontaneous position of comfort, preferential head turning,
active neck rotation and cranial flattening. The outcome of
the postural syndrome was graded as disappeared,
improved,”“persistentor aggravated.The necessity of
other therapeutic treatments (physiotherapy, osteopathy)
was noted.
Statistical analysis
The statistical analysis of the risk factors relies on three
groups of logistic regressions in which the dependent
variables were the absence or the presence of MBS 1, 2
or 3. Data were tested for statistical significance with
Pearson χ
2
tests and analysed using univariant and multi-
variant logistic regressions. The regression coefficients of
dependent variables were transformed into odds ratios (OR)
with 95% confidence intervals. An OR was considered to
be significant only if its confidence interval did not contain
the value 1.00. Differences were considered to be signifi-
cant if pwas <0.05.
Results
Cohort characteristics
One thousand and one neonates were included in the study.
There were 504 girls and 497 boys, with 953 singletons and
48 twins from 24 pairs. A caesarean section was carried out
for 216 singletons and 18 twins. Among the 748 singletons
and 30 twins born vaginally, 120 instrumental assistances
were required. The gestational ages ranged from 32 to
43.7 weeks, with 121 premature neonates (gestational age
<37 weeks) and 118 post-term neonates (gestational age
>41 weeks). The birth weights ranged from 1,630 to
5,280 g, with an average of 3,108 g. The birth lengths
ranged from 40 to 55 cm, with an average of 49.4 cm. Boys
were, on average, heavier by 176 g and longer by 0.48 cm
(p<0.001). The average maternal age was 29.5 years (range
14 to 45 years), with 44% of primiparity and 56% of
multiparity. There were 932 (93%) vertex presentations, 64
(6.4%) breech presentations and 8 (0.8%) transverse
presentations. Sixty-seven (6.7%) mothers experienced a
preterm labour, 52 (5.2%) had pregnancy toxaemia and 10
(1.0%) had an oligoamnios.
Prevalence of MBS
MBS was detected in 107 neonates (10.7%), 50 girls and 57
boys (male versus female ratio of 1.14:1). The MBS scores
ranged from 1 to 7, with an average of 1.9 per newborn.
The frequencies and different components of the MBS are
reported in Table 1. There were 97 cases of MBS 1 (9.7%
of the 1,001 infants), among which 75 (77%) were isolated:
31 posterior plagiocephalies (25 right-sided and six left-
sided), seven frontal plagiocephalies (three right-sided and
four left-sided), nine head tilts (two to the right and seven
to the left) and 74 preferred head orientations (61 right-
sided and 13 left-sided). Among the 74 head rotations, only
21 (28%) were associated with a limitation in or a
resistance to the passive contralateral rotation, and only
23 (30%) were combined with a plagiocephaly. No infant
had a sternocleidomastoid contracture or palpable mass in
the sternocleidomastoid muscle (prevalence in the litera-
ture: 0.4% [3]). The male versus female ratio for MBS 1
was 2:1. There were 25 cases of MBS 2 (2.5% of the 1,001
neonates), among which five (20%) were isolated: eight
truncal curvatures, 18 pelvic obliquities, seven adductor
hypertonia and 16 abduction limitations (six unilateral, ten
bilateral). The truncal curvatures were all associated with a
turned head (the convexity being on the occipital side of the
turned head) and with a pelvic obliquity. Eighty-four
percent of the pelvic obliquities and all of the unilateral
abduction limitations were associated with MBS 1, and all
showed adduction contracture of the hip on the occipital
side of the turned head. Three neonates had a hip
Table 1 Frequency of the three types of moulded baby syndrome
(MBS) among the 1,001 neonates
MBS type Frequency
Neonates with an isolated
component of MBS
MBS 1 75
MBS 2 5
MBS 3 3
Neonates with an association
of two components of MBS
MBS 1 + MBS 2 14
MBS 1 + MBS 3 4
MBS 2 + MBS 3 2
Neonates with completeMBS MBS 1 + MBS 2 + MBS 3 4
Eur J Pediatr (2009) 168:605611 607
dislocation. They were isolated in two, without association
to any of the other elements of MBS, and combined with a
genu recurvatum in one. None of them had a vertex
presentation or a family history of congenital dislocation of
the hip. Their birth weights (3,510, 3,760 and 4,010 g,
respectively) were well above average. Thirteen neonates
had MBS 3 (1.3% of all neonates), with three being
isolated: one genu recurvatum, five talus valgus (four
associated with a turned head on the occipital side) and
seven metatarsus adductus. Four infants had complete MBS
with all three components.
Risk factors of MBS
The frequencies of MBS were analysed according to the
mothers age and parity, obstetrical events and to the
newborns characteristics, and the corresponding ORs were
calculated.
Mother-dependent risk factors: 19.5% of the neonates
with a mother over 36 years of age had MBS versus 9.4%
of those whose mother was under 30 years of age (Table 2).
The mothers age was a significant risk factor for MBS 1
(OR= 1.39, p=0.018) and MBS 2 (OR=1.13, p=0.013).
There were 16.1% MBS neonates among those from
primiparous versus 8.2% from multiparous mothers (Table 3).
Multiparity is a significant protective factor for MBS 1
(OR= 0.643, p=0.010).
Obstetrical risk factors (Table 4): multiple pregnancy was
not a risk factor for MBS, as only two twins (4.2%) had a
torticollis. Twelve neonates (17.9%) with a history of preterm
labour had MBS, which was statistically significant (OR=
1.65, p=0.015 for MBS 1 and OR= 1.48, p=0.035 for MBS
2). Five neonates (50%) with an oligoamnios had MBS
(MBS 2 essentially: OR=10.179, p= 0.041). Pregnancy
toxaemia led to MBS in eight newborns (15.3%), with 75%
of MBS 2 and an OR=3.773, p= 0.041. Breech and
transverse presentations were significant risk factors for
MBS 1 (OR=2.746, p=0.019)with12(16.7%)ofthese
neonates having MBS (all but one being MBS 1). The
necessity for instrumental delivery was associated with MBS
in 37 newborns (30.8%), with an OR of 6.028 (p=0.019).
Infant-dependent risk factors: the only significant newborn-
dependent risk factors were the male gender (OR=1.982,
p=0.019) and the birth length (OR= 1.196, p=0.023) for
MBS 1. The ponderal index P/T
3
had a protective role (OR=
0.910, p=0.035) for MBS 1.
No risk factor was specifically found for the onset of
MBS 3.
Oral evaluation of the outcome of MBS 1 at 2 to 3 months
of age
Among the 97 neonates with a plagiocephaly or torticollis,
handling suggestions were given to one or both of the
parents for 81 neonates (84%), the others being either
absent during the infants examination or there being a
language obstacle. All of them agreed to be contacted by
phone 2 to 3 months later to evaluate the outcome after
several months of positioning. We were able to reach 65
families (80%). Altogether, MBS 1 disappeared in 43
infants (66%), improved without having totally disappeared
in seven (11%), persisted without change in three (5%) and
Table 3 MBS according to parity
Parity (P) Number of neonates Number of neonates with MBS Number of neonates with each MBS component
MBS 1 MBS 2 MBS 3
P1 428 69 (16.1%) 45 17 9
P2 302 30 (10.0%) 29 2 3
P3 149 11 (10.1%) 14 3 3
P4 50 3 (6%) 3 0 0
P5 30 0 0 0 0
Unknown 33 4 (12%) 4 1 0
Table 2 MBS according to the mothers age
Maternal age (years) Number of neonates Number of neonates with MBS Number of neonates with each MBS component
MBS 1 MBS 2 MBS 3
Under 30 465 44 (9.5%) 39 16 5
3035 313 31 (10%) 28 11 2
Over 36 156 30 (19.4%) 23 6 6
Unknown 67 2 (3%) 2 1 0
608 Eur J Pediatr (2009) 168:605611
worsened in 12 (18%). Among 45 isolated head rotations,
37 disappeared (82%), one seemed persistent (3%) and
seven (15%) worsened with the creation of a plagiocephaly.
We were only able to reach eight infants with an isolated
occipital plagiocephaly at birth: two disappeared (25%),
four improved (50%) and two became worse (25%).
Among 12 neonates with a plagiocephaly associated with
a head rotation or head tilt, three disappeared (25%), four
improved (33%), two seemed identical (17%) and three
worsened (25%). None evolved in a real muscular
congenital torticollis with either a palpable mass or a
sternocleidomastoid contracture. Two families chose to see
an osteopath for their childs plagiocephaly and head
rotation, and ascertained that both had resolved after 1 to
2 months of treatment.
Discussion
Postural deformations are frequent in foetuses and neo-
nates. This can be explained by the intensive growth, great
plasticity and extrapyramidal reflex activity of the newborn
developing in a restricted environment [10]. MBS is an
association of one or several postural deformities of the
face, skull, spine, pelvis, hips, knees and feet. It has already
been described by several authors [13,18,21], but there is
no consensus as to the risk factors of this syndrome. Our
results confirm the high frequency (10.7%) of MBS among
1,001 healthy newborns. The published incidence of MBS
among neonates ranges from 0.6% [13] to 13% [21].
We found a preponderance of MBS 1 (plagiocephaly or
torticollis), affecting 9.7% of all neonates. The term torticollis
refers to any asymmetrical posturing of the head and neck,
although it has, unfortunately, become synonymous with one
of its prevalent severe forms: congenital muscular torticollis.
Unlike Hamanishi and Tanaka, who observed a prevalence of
13% of palpable mass in the sternocleidomastoid muscle
among neonates with a spontaneous head rotation [13], we
did not note such a mass among any of our patients. The fact
that infants are usually considered normal at birth and that
the sternocleidomastoid contracture or the fibrous mass often
appears at 2 to 3 weeks of age [3] could account for this
difference. Most of the plagiocephalies and head rotations
were right-sided (81% and 82%, respectively), as has been
frequently described [2,4,13,15,20,21,24]. Hamanishi
and Tanaka noted a statistical correlation between the side of
the neonatal torticollis and the side of the foetus lying on the
mothersspine[13], and Peitsch et al. suggested that the
higher frequency of right-sided plagiocephaly could be
linked to the preponderance of the lateralisation of the
infants presentation, with the foetusright occiput being
compressed against the maternal pelvic bone in the left
occipital anterior presentation [21]. The ipsilateral coexis-
tence of truncal curvature, adduction contracture of the hip
or foot adduction with plagiocephaly or head turning
(specifically on the occipital side of the turned head) has
also been evidenced by others [11,13,26]. In a study on
1,500 neonates, Seringe et al. also showed a relationship
between in utero positioning and orthopaedic deformities of
the lower limbs [22]. In another paper, Seringe et al. precised
that a congenital asymmetrical pelvis was associated with a
dysplasia dislocation of the hip (DDH) in 23% (27 out of
120) infants [23]. This proportion is similar to what we
found in our cohort (three DDH for 18 asymmetrical pelvis).
This study specified the risk factors of MBS based on a
cohort of 1,001 newborns, all examined by the same
paediatrician. The risk factors that we highlighted depended
on the mother (age, parity), the course of pregnancy and
delivery (preterm labour, oligoamnios, pregnancy toxaemia,
breech presentation, instrumental delivery) and on the
newborn (gender, birth length and ponderal index). These
factors correspond to an inadequacy between the container
(the mothers uterus and pelvis) and the content (the
foetus), with an excessive pressure exerted on the foetus.
It can be considered that a primiparasuterusand
abdominal muscles are more tonic than that of a multipara,
whereas the uterus becomes fibrous and less flexible with
greater age. In premature labour, the contractions exert
repeated excessive pressure on the foetus, and the pressures
are less alleviated in case of an oligoamnios. Finally,
foetuses in breech presentation are also subjected to higher
compression, especially toward the end of pregnancy, when
Table 4 MBS according to obstetrical events
Obstetrical events Number of neonates Number of neonates with MBS Number of neonates with each MBS component
MBS 1 MBS 2 MBS 3
Preterm labour 67 12 (17.9%) 9 6 2
Pregnancy toxaemia 52 8 (15.3%) 6 5 0
Oligoamnios 10 5 (50%) 3 2 2
Breech or transverse presentation 72 12 (16.7%) 11 3 2
Instrumental delivery 120 37 (30.8%) 36 4 1
Multiple pregnancy 48 2 (4.2%) 2 0 0
Eur J Pediatr (2009) 168:605611 609
the narrow tip of the uterine horns provides only limited
space for the developing cranium of the foetus. Our results
concerning mother-dependent factors (age and primiparity)
are in accordance with othersobservations [2,4,6,8,9,
1113,17,21,26]. Peitsch et al. found 63% of primipara in
their population of newborns with plagiocephaly versus
37% of primipara in normal-shaped newborns [21].
Hamanishi and Tanaka also observed a significant prepon-
derance of first-born children and neonates with mothers of
an age higher than average, and concluded that a tight
uterus is almost invariably associated with MBS in a child
delivered by vertex presentation [13]. As to obstetrical risk
factors, our results are in line with other published data
concerning oligoamnios [12,17], breech presentation [2,6]
and instrumental delivery [8,21]. The influence of preterm
labour and toxaemia had not, to our knowledge, been
studied before. Unlike what we expected and what had
been published previously [8,13,15,17,21], multiple-birth
pregnancy was almost never associated with MBS in our
study population, whereas an occipital flattening was
described by Peitsch et al. in up to 56% of twins [21] and
an incidence of 44% of postural asymmetry was reported
by Hamanishi and Tanaka [13]. As to infant-dependent
factors, the observation that boys are more frequently
affected than girls in terms of torticollis and plagiocephaly
has frequently been published [4,5,7,15,16,1921] and
could be explained by a greater average birth length. Unlike
what could be expected, birth weights and head circum-
ferences were not significant risk factors for MBS, which
has also been observed [21].
Parents of neonates with MBS 1 at birth were given
positioning and stimulation advice. We did not include a
control group with untreated neonates because we believed
that, having noted the torticollis, leaving it unmentioned
would not be ethical. Sixty-five infants were reevaluated by a
phone survey during the third month of life. Over 75% of
MBS 1 occurrences disappeared or improved with the parents
following the advice that they were given. These measures
seemed to be the most efficient when only an isolated head
rotation was involved, and less when there already existed a
plagiocephaly at birth. These results tend to confirm the
hypothesis that neonates with turned or tilted head or cranial
flattening at birth will develop full deformational plagioce-
phaly [2,14,21,25] or a muscular congenital torticollis if
they are left unnoticed, the congenital deformation being
perpetuated and accentuated by pressure from the mattress
[11,21], and that this evolution could, in part, be avoided
with active home positioning and stimulation. We neverthe-
less acknowledge the fact that only a study including a
control group could ascertain this hypothesis.
The findings of this investigation thereby confirm the
importance of a careful orthopaedic neonatal examination
to detect MBS, an association of postural deformities
affecting over 10% of healthy neonates. In the presence of
MBS2, clinicians must be particularly alert for DDH, which
is associated in nearly 20% of cases. Analysis of the MBS
risk factors demonstrated that newborns of male gender or
of greater birth length, with an older primiparous mother,
an obstetrical history of preterm labour, oligoamnios or
pregnancy toxaemia, a breech presentation or an assisted
delivery were statistically more likely to develop MBS.
Special concern should be given to the detection of a
neonatal torticollis or plagiocephaly, as early simple
positioning and stimulation measures can improve their
spontaneous outcome. Parents and paediatricians must,
therefore, be alert regarding subtle neonatal deformations.
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... A diagnosis of IIS was made, and the patient was referred to an orthopedic surgeon for an assessment. Molded baby syndrome was listed as a differential diagnosis; however, the absence of hip contracture and ear or foot abnormalities and the direction of the cervical restriction [17,18] made this less likely. ...
Article
Full-text available
Background The recommended treatment for mild to moderate infantile idiopathic scoliosis curves involves serial casting. There are concerns, however, regarding the safety of repeated casting in very young children owing to the requirement for anesthetization during the casting process. Very little research has been conducted on the influence of bracing as an initial treatment for scoliosis in this age group. This report details the successful treatment of a large thoracic curve using a thoracolumbosacral orthosis in an infant diagnosed with infantile idiopathic scoliosis. Case presentation The Dutch-Australian patient presented at 11 weeks of age with a 44° thoracic scoliosis and a rib vertebral angle difference of 14°. The history and physical examination failed to reveal a cause of the curvature, and a diagnosis of infantile idiopathic scoliosis was made. The patient was prescribed a thoracolumbosacral orthosis ( ScoliBrace ) to be worn on a part-time basis for a period of 8 months. At the end of the bracing program, the patient’s curve had been reduced to 7° and a rib–vertebral angle difference of 0°. A final follow-up of the patient at 2 years after the cessation of treatment revealed no evidence of scoliosis. The parents were compliant with the bracing protocol and reported that the treatment was tolerated by the infant. Conclusion The use of an orthosis as a standalone treatment in this patient resulted in significant reduction in a large thoracic scoliosis. Based on the results witnessed in this patient, further investigation into bracing as an alternative to casting is warranted.
... Intrauterine Kräfte können bereits pränatal zu Kopfverformungen führen [18,22]. Ursprung dieser Kräfte können entweder intrauterine Zwangslagen [23][24][25] oder ein vermindertes intrauterines Platzangebot, beispielsweise aufgrund einer Mehrlingsgeburt, sein [23,[25][26][27][28]. Insbesondere bei erstgebärenden Müttern ist aufgrund der noch nicht vorgedehnten Strukturen das Risiko für bereits intrauterin entstehende Kopfverformungen erhöht [19,23,25,27,29,30]. ...
Thesis
Zur Kopforthesentherapie in der Behandlung von Säuglingen mit lagerungsbedingten Schädelasymmetrien gibt es bisher kaum Studien, die den optimalen Behandlungsbeginn unter Berücksichtigung der Ausprägung der Asymmetrie untersuchen. Ziel der vorliegenden Studie war es daher, den Einfluss des Alters und des Schweregrades der Asymmetrie bei Therapiebeginn auf die Therapiedauer und das Therapieergebnis zu analysieren. Hierzu wurden 144 Patienten mit lagerungsbedingtem Plagiozephalus untersucht, die mittels Kopforthese behandelt wurden. Es erfolgte eine Einteilung in drei Altersgruppen (Altersgruppe I: < 24 Wochen mit N = 38 Säuglingen / Altersgruppe II: ≥ 24 bis < 32 Wochen mit N = 79 Säuglingen / Altersgruppe III: ≥ 32 Wochen mit N = 27 Säuglingen) und je zwei Schweregrade (mild-to-moderate: 30°-CVA >3mm bis <12mm / moderate-to-severe: 30°-CVA ≥12mm). Anhand stereophotogrammetrischer Datensätze wurden das Ausmaß und die Reduktion der Asymmetrie in den verschiedenen Untergruppen sowie die Therapiedauer miteinander verglichen. Es zeigte sich, dass es in allen Altersgruppen zu einer signifikanten Reduktion der Asymmetrie kam, wobei sich dieser Effekt mit steigendem Alter verringerte. Ein Therapieerfolg (= CVAI <3,5%) wurde bei Patienten mit mild-to-moderate Asymmetrie in Altersgruppe I zu 83%, in Altersgruppe II zu 69% und in Altersgruppe III zu 40% erreicht. Bei Patienten mit einer schwerwiegenderen, moderate-to-severe Asymmetrie ergab sich eine symmetrische Kopfform zu 50% in Altersgruppe I, zu 30% in Altersgruppe II und nur zu 7% in Altersgruppe III. Die durchschnittliche Therapiedauer stieg von 18,6 Wochen in Altersgruppe I, 20,0 Wochen in Altersgruppe II und 25,3 Wochen in Altersgruppe III an. Das Alter bzw. der Schweregrad der Asymmetrie bei Behandlungsbeginn wurden durch die multiple Regressionsgleichung ins Verhältnis gesetzt. Dadurch kann zukünftig die zu erwartende Verbesserung der Asymmetrie durch eine Kopforthesentherapie abgeschätzt werden. Zusammenfassend kann somit festgestellt werden, dass das Alter bei Therapiebeginn sowie der Ausprägungsgrad einer lagerungsbedingten Asymmetrie einen entscheidenden Einfluss auf Dauer und Effektivität der Kopforthesentherapie haben. Die Erfolgsrate der Therapie ist maßgeblich von diesen beiden Einflussfaktoren abhängig. Die aufgestellte Regressionsgleichung ermöglicht eine Vorhersage der Reduktion einer lagerungsbedingten Schädelasymmetrie.
... Infants are more variable in behaviour and movement, and less able to follow commands or tolerate equipment [5]. Many studies investigating various aspects of torticollis have included neck ROM as an outcome measure but give limited detail about how ROM was measured [34][35][36][37][38][39][40][41]. Others give details of the assessment tool used, but psychometric properties are not described [8,12,[42][43][44][45] or are described for an adult population [46,47]. ...
Article
Full-text available
There is a lack of reliable and valid measurement tools to assess neck function in infants with congenital muscular torticollis, and most physiotherapists use visual estimation, which has not been adequately tested for reliability in this population. We examined the reliability of visual estimation of head tilt and active neck rotation in the upright position, on infants with congenital muscular torticollis by physiotherapists. We recruited 31 infants and 26 physiotherapists. Therapists rated videos of infants’ head position in the frontal plane (tilt) and transverse plane (active rotation) using visual estimation, on two occasions at least one week apart. Overall, inter-rater reliability was good (mean ICC, 0.68 ± 0.20; mean SEM, 5.1° ± 2.1°). Rotation videos had better reliability (mean ICC, 0.79 ± 0.14) than head tilt videos (mean ICC, 0.58 ± 0.20). Intra-rater reliability was excellent (mean ICC, 0.85 ± 0.08). Both head tilt and rotation had excellent reliability (mean ICC, 0.84 ± 0.08 for head tilt and 0.85 ± 0.09 for rotation). There was no correlation between intra-rater reliability and clinical experience. Conclusion Visual estimation had excellent intra-rater reliability in the assessment of neck active rotation and head tilt on infants with congenital muscular torticollis. Visual estimation had acceptable inter-rater reliability in the assessment of neck active rotation but not of head tilt. There was a wide variation in reliability with no correlation between reliability and clinical experience. Assessment tools for head tilt that are more psychometrically robust should be developed.What is Known: • A thorough assessment of infants presenting with torticollis is essential, using assessment tools with robust psychometric properties • Visual estimation is the most commonly used method of assessment of neck function in infants with torticollis What is New: • Visual estimation had excellent intra-rater reliability in the assessment of neck active rotation and head tilt in the upright position in videos of infants and acceptable inter-rater reliability in the assessment of rotation but not of head tilt • Physiotherapists’ clinical experience had minimal relationship with reliability
... Intrauterine breech presentation and breech delivery have been shown to predispose to increased neonatal hip-joint instability requiring treatment [1][2][3]. Intrauterine constriction not only contributes to the developmental dysplasia of the hip (DDH) but also to head shape asymmetries like plagiocephaly and brachycephaly [4][5][6][7]. Furthermore DDH coexists sometimes with congenital muscular torticollis in infancy [8][9][10]. ...
Article
Full-text available
Developmental dysplasia of the hip (DDH) may require early abduction treatment with infants sleeping on their back for the first few months of life. As sleeping on back is known to cause deformational plagiocephaly, we assessed school age children treated for dislocation or subluxation of the hip-joint in infancy. Plagiocephaly was analyzed by using cephalic index (CI) and oblique cranial length ratio (OCLR) as anthropometric measurements from 2D digital vertex view photographs. Six of the 58 (10.3%) DDH children and only one of the 62 (1.6%) control children had plagiocephaly (p = 0.041). Furthermore, cross bite was found in 14 (24.1%) of the DDH children and in 7 (10.3%) of the control children. Developmental dysplasia of the hip in infancy was associated with cranial asymmetries and malocclusions at school age. Preventive measures should be implemented.
... It seems likely that all the aforementioned intrauterine conditions lead to PDP through muscle imbalance and/or position preference more than through a direct skull deformation. • Perinatal risk factors (Cheng et al. 2000;Golden et al. 1999;Kumandas et al. 2006;Kuo et al. 2014;Leung et al. 2017;Losee et al. 2007;McKinney et al. 2009;Pogliani et al. 2011;Rogers et al. 2009;Rubio et al. 2009;Stellwagen et al. 2008). Congenital diseases, ranging from chromosomal anomalies to neurological, respiratory, gastrointestinal, and urological pathologies, are clearly recognized as possible causes of PDP because of the reduced fetal/newborn motility resulting from neurological deficits, psychomotor delay, repeated surgical operations, and long hospitalization. ...
Article
Introduction. Posterior Positional plagiocephaly (PPP) is a cranial deformation seen in infants. The case number increased since 1992, following the supine sleeping advice. Most of the time several factors are combining together, leading to a multi-level lack of mobility of the infant, thus leading to the cranial deformation. Studies show this deformation to be linked with perturbations in various fields. Objective. This study aims to assess the efficacy of osteopathic care on the severity of the PPP. Materials and methods. 100 infants were recruited in an osteopathic practice in Lyon (France). All the infants followed the same study protocol; however, the treatment was individualized. Three consultations occurred with a 15 days′ interval over 30 days′ period. Craniometric measurements were realized with Mimos® craniometer on each consultation. Results. The mean severity of the PPP was 10,1 mm at Day 0. At day 30, this average was down to 6 mm. It is a significant (p<0,001) clinical and statistical decrease. Out of the 100 infants, 98 had a decreased deformation while two stagnated. Conclusions. As every infant is unique, every plagiocephaly is different, thus the treatment was not standardised. This study suggest some effectiveness for osteopathic care in the cranial asymmetry of infants with PPP. Other studies should be done, some with a control group, in order to compare our results with spontaneous evolution of plagiocaphaly.
Article
Approximately 10% of all infants in Germany suffer from infantile postural asymmetry, which is treated with a wide variety of treatments. Worldwide there are only few efficacy studies, mostly covering the disorders plagiocephaly and torticollis. Furthermore, there are also inadequate studies with large samples. Some of the treatments that are used have been barely evaluated. This is also why doctors still tend to wait for possible improvements without prescribing physical therapy. The purpose of this study, using the Delphi method, is to obtain agreement among international experts concerning the efficacy of different therapy treatments for infantile postural asymmetry. These outcomes can be used to promote additional, research and to justify treatment decisions. A consensus is achieved when more than 80% of all experts are either pro or contra a specific treatment. Using the Delphi method type 4 (Consensus Delphi), there will be four survey rounds aiming for a consensus. International experts were chosen by literature research. Those experts were exclusively physical therapists. In round 1, we collected treatments used by the experts; in round 2 we quantified these treatments using a Likert-type scale. Furthermore, in round 3, we collected arguments for and against each treatment from the experts and presented these to them in round 4. In this last round the experts again judged the efficacy of each treatment and evaluated their use for the future. We collected a total of 22 treatments. For three of them a positive consensus could be confirmed. Those treatments are prevention - parental training concerning day and night positioning (95% consensus), prevention - parental training concerning handling, (90% consensus) prevention – parental training concerning motoric development (86% consensus). The evaluation of the international experts represents the lack of clarity on efficacy of therapies for infantile posturale asymmetry. This could be the reason why preventive methods have been evaluated better then curative methods. Preventive treatments have been used by all experts and should be part of a comprehensive program in prenatal classes to prevent consequential disorders. Retrospectively one could evaluate whether the programs reduce the incidence of infantile posturale asymmetry. According to stretching exercises, an RCT could be used to evaluate efficacy. Therefore, possible side effects must be observed. Even though all experts use stretching exercises, no consensus was reached.
Article
Background: All over Europe the Vojta therapy is an acknowledged method and is commonly used, especially in Germany. Despite that, there is lack of scientific proof of this concept’s efficacy. Objective: A standardized assessment was used to document the restriction in head rotation and the convexity of the spine in both, the prone and supine position before and after the eight weeks of therapy. A minimum of four points mean reduction in congenital muscular torticollis within the Vojta group and a comparison of the cumulative score difference of the two groups were analyzed to evaluate the efficacy of Vojta therapy. Method: Vojta was compared to general physiotherapy aiming for improvement in congenital muscular torticollis. Therefore n = 37 infants diagnosed with torticollis were randomized into two groups and treated accordingly. The children received two treatments per week. In addition, their parents were trained and asked to continue the routine four times per day. Three blinded assessors were assigned to analyze the 74 videos to evaluate the efficacy through pre- and post-test comparison. Results: The minimum of four point mean for clinical relevance was achieved by both the intervention as well as the control group. Based on the findings of the three assessors Vojta showed significantly (p .006) better results in reducing congenital muscular torticollis in within-group comparison after the treatment period. Conclusion: Provided that Vojta therapy is starting within the first four months of life it reduces congenital muscular torticollis significantly more than general physical therapy.
Article
Smith's Recognizable Patterns of Human Deformation is the only book devoted to the diagnosis and management of birth defects resulting from mechanical forces in late gestation. It equips you with the evidenced-based guidance you need to intervene in a timely and effective manner to avoid long-term adverse secondary consequences. Guides you through the initial clinical approach to suspected deformation problems, and then walks you through pathogenesis, diagnostic features, management, prognosis, and counseling for each condition. Addresses a full range of lower extremity deformations joint dislocations nerve palsies chest and spinal deformations head and neck deformations craniosynostoses and cranial bone variations problems associated with abnormal birth presentation, birth palsies, and procedure-related defects infant head shape variations and torticollis. Helps you to distinguish deformations from malformations so you can manage them appropriately.
Article
Although prospective randomized clinical trials have not been performed, the weight of evidence implicates the prone position as a significant risk factor for SIDS. There is some concern that many of the studies have come from countries and regions with SIDS rates which are significantly higher than that of the United States. Nevertheless, the consistency of the results from a variety of countries makes it more likely that the data should be applicable to this country as well. In addition for the healthy infant there appears to be little hazard associated with the lateral or supine positions. The preponderance of data have come from studies that asked about 'usual' sleep position, as opposed to position 'when found dead' or 'last position seen.' Nevertheless, during the first few months after birth, it appears as if the position in which the infant is first placed will substantially determine the position that the infant will maintain throughout sleep. Therefore, it appears reasonable to recommend that most healthy infants be placed in the lateral or supine position. Many will advocate development of a carefully controlled clinical trial to test definitively the relationship of sleep position and SIDS. In view of the large population required for a study, the requirement for lay participation in any trial, and the bias that has already been introduced by previous publications and the lay press, it appears unlikely that such an impartial controlled trial could be conducted. However, there are techniques other than the controlled trial that can be used to evaluate this issue further. We encourage ongoing rigorous analysis of the relationship between sleeping position and SIDS in the United States. Subsequent increases or decreases of the incidence of SIDS in the United States may reflect a change in sleeping position or a change in some other variable. Watching for and reporting possible changes in selected regions during the next decade must be a high research priority for investigators and funding agencies. Although not the subject of this review, it is important that society recognize that other potentially alterable factors have also been shown to be associated with SIDS. Maternal smoking and prematurity have both been identified as risk factors; breastfeeding has been associated with a decreased risk. Programs aimed at changing these variables may well lead to improved rates. Also, we want to emphasize that there are still good reasons for placing certain infants prone. For premature infants with respiratory distress, infants with symptoms of gastroesophageal reflux, infants with certain craniofacial anomalies or other evidence of upper airway obstruction, and perhaps some others, prone may well be the position of choice. It should be stressed that, although the relative risk of the prone position may be several times that of the lateral or supine position, the actual risk of SIDS when placing an infant in a prone position is still extremely low. In conclusion, after evaluation of all available evidence to date, for the well infant who was born at term and has no medical complications, the Academy recommends that these infants be placed down for sleep on either their side or back.
Article
Plagiocephaly is a term commonly used to describe congenital forehead asymmetry. Sixty patients with frontal plagiocephaly were evaluated retrospectively and separated into three types: synostotic (N = 24), compensational (N = 3), and deformational (N = 33). Categorization of frontal plagiocephaly as synostotic or deformational was reliably made by physical examination, focusing on the supraorbital rims, nasal root, ears, and malar eminences. Other anatomic parameters useful in the differential diagnosis included chin point, palpebral fissures, and facial height. This study documented that birth histories were similar for synostotic and deformational frontal plagiocephalic infants. However, other deformational anomalies were more common in deformational frontal plagiocephalic infants, whereas malformations had an equal incidence in deformational and synostotic frontal plagiocephalic infants. Torticollis was an associated finding in 64 percent of infants with deformational frontal plagiocephaly; almost all were ipsilateral. In contrast, head tilt, usually to the contralateral side, was noted in 14 percent of patients with synostotic frontal plagiocephaly. Female preponderance was noted in both synostotic (79 percent) and deformational (76 percent) frontal plagiocephaly. Left-sided involvement was seen in 73 percent of patients with deformational frontal plagiocephaly and in 46 percent of patients with synostotic frontal plagiocephaly. Premature pelvic descent, in the left occipital anterior position, may account for the high incidence of left-sided deformational plagiocephaly and ipsilateral torticollis.
by John M. Graham Jr, MD, ScD, 361 pp, $89, ISBN-13 978-0-7216-1489-2, Philadelphia, Pennsylvania, Saunders Elsevier, 2007.
Article
With few exceptions, congenital anomalies may be subdivided into 'malformations', which arise during the embryonic period as a result of primary errors in morphogenesis, and 'deformations', which arise in later fetal life and are alterations in the form or structure of a previously normally formed part. The great majority of deformations involve the musculoskeletal system and have been called the congenital postural deformities. Since 1959 a number of clinical, radiologic and pathologic studies have been undertaken respecting the etiology of these deformities. The present paper reviews this work and the evidence in support of the mechanical theory. This theory states that congenital postural deformities are caused by intra uterine moulding; that while the pressure required to produce such moulding may occasionally arise intrinsically because of muscle imbalance secondary to neuromuscular disease, in most cases it is of extrinsic origin, arising in the later weeks of pregnancy as the volume of amniotic fluid diminishes and the still plastic and rapidly growing fetus becomes constrained within the uterus. All parts of the infant may be affected, the most important deformities being the various forms of talipes, congenital sternomastoid torticollis, congenital postural scoliosis, and congenital dislocation of the hip. Less common or less important deformities include congenital bowing of the legs, congenital genu recurvatum, deformities of the upper limbs and thorax, the Potter's or compression facies, congenital plagiocephaly and dolichocephaly, retrognathia and mandibular asymmetry, and facial, radial, obturator and sciatic neuropraxias. Some cases of mid line cleft palate, multiple congenital arthrogryposis, and syndactyly also appear to have a mechanical origin.
Article
In congenital pelvic obliquity, there is a restricted abduction in one hip and an abduction contracture in the other. This association has been considered as a cause of acetabular dysplasia with progressive subluxation of the hip opposite to the abduction contracture. The clinical and radiological study of 120 children with an average follow-up of 3 years and 3 months permitted to demonstrate that two different types exist: the simple types (93 cases) without dysplasia, which never developed progressive subluxation and must not be treated, and the pelvic obliquities with dysplasia-subluxation-dislocation (27 cases) which have to be treated if the decentration of the hip opposite to the abduction contracture is marked. Distinguishing between these two types may be difficult because the X-ray is nearly never strictly correct because of the pelvic obliquity. This work leads to a better comprehension of the acetabular dysplasias who are subdivided into pseudodysplasias, secondary dysplasias and primary dysplasias. In the screening for the detection of congenital dislocation of the hip, it is essential that a pelvic obliquity be recognised because it constitutes a sign of hip at risk. Then, the clinical research of instability could be completed by echographic study in the two or three months or by radiographic study after 3 months in order to have a very precise diagnosis and apply the best treatment.
Article
Plagiocephaly is a term commonly used to describe congenital forehead asymmetry. Sixty patients with frontal plagiocephaly were evaluated retrospectively and separated into three types: synostotic (N = 24), compensational (N = 3), and deformational (N = 33). Categorization of frontal plagiocephaly as synostotic or deformational was reliably made by physical examination, focusing on the supraorbital rims, nasal root, ears, and malar eminences. Other anatomic parameters useful in the differential diagnosis included chin point, palpebral fissures, and facial height. This study documented that birth histories were similar for synostotic and deformational frontal plagiocephalic infants. However, other deformational anomalies were more common in deformational frontal plagiocephalic infants, whereas malformations had an equal incidence in deformational and synostotic frontal plagiocephalic infants. Torticollis was an associated finding in 64 percent of infants with deformational frontal plagiocephaly; almost all were ipsilateral. In contrast, head tilt, usually to the contralateral side, was noted in 14 percent of patients with synostotic frontal plagiocephaly. Female preponderance was noted in both synostotic (79 percent) and deformational (76 percent) frontal plagiocephaly. Left-sided involvement was seen in 73 percent of patients with deformational frontal plagiocephaly and in 46 percent of patients with synostotic frontal plagiocephaly. Premature pelvic descent, in the left occipital anterior position, may account for the high incidence of left-sided deformational plagiocephaly and ipsilateral torticollis.
Article
Sternocleidomastoid muscle fibrosis has been recognized for centuries, but its pathogenesis and treatment remains controversial. Pseudotumor of infancy is a firm fibrous mass in the sternocleidomastoid muscle appearing at 2 to 3 weeks of age. Congenital muscular torticollis is less common and appears later in life. Pseudotumor and congenital muscular torticollis probably represent different manifestations of sternocleidomastoid muscle fibrosis. Pseudotumor will usually resolve with conservative therapy; however, some patients will subsequently develop torticollis. Congenital muscular torticollis usually requires surgical release of the sternocleidomastoid muscle to achieve a good cosmetic result and to prevent plagiocephaly, facial asymmetry, and scoliosis. This report provides guidelines for the management of congenital muscular torticollis and pseudotumor of infancy based on the authors' experience and review of the medical literature. Representative case histories from the neonate through the adult are presented, and the pathogenesis, diagnosis, treatment, and prognosis are discussed.
Article
The belief that certain congenital anomalies might be caused by mechanical factors in utero dates back to Hippocrates and has been readvanced in our own times by Browne (1936, 1955) and Chappie & Davidson (1941). However, the hypothesis was for the most part based on anecdotal clinical evidence and, at any rate by 1960, had failed to gain wide support (Browne 1960, Corner 1960). In that year I commenced a number of clinicopathological studies on this subject which were brought together in a thesis in 1969. In this paper I shall summarize some of the epidemiological data collected between 1960 and 1963.