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Posterior positional plagiocephaly treated by cranial remodelling orthosis

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Since the recommendation that infants sleep in the supine position, there has been an increase in cases of posterior positional plagiocephaly. Even though this condition is a purely cosmetic problem, if it is severe it may affect the child psychologically. Positioning may help in mild or moderate cases, but more active treatment may be necessary in severe cases. A prospective study of 260 children treated by dynamic orthotic cranioplasty for posterior positional plagiocephaly was conducted in Lausanne from 1995 to 2001. Construction of these cranial remodelling helmets is decribed in detail. The treatment lasted 3 months on average, was effective, well tolerated, and had zero morbidity. The ideal period for initiating this therapy is between the ages of 4 and 6 months. The remodelling helmet is a convincing option which can be recommended in infants with posterior positional plagiocephaly whose skull deformity is not satisfactorily corrected by physiotherapy. It should always be used before surgery is considered for patients with recognised positional plagiocephaly in the first year of life.
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Posterior positional plagiocephaly treated
by cranial remodelling orthosis
Lausanne’s experience with 260 children
S. de Ribaupierrea, O. Verneta, B. Rillieta, B. Cavinb, D. Kalinaa, P.-F. Leyvrazb
aService of Neurosurgery, Centre Hospitalier Universitaire Vaudois, Lausanne-CHUV, Switzerland
bDepartment of Orthopaedic Surgery, Hôpital Orthopédique de la Suisse Romande, Lausanne,
Switzerland
Principles: Since the recommendation that in-
fants sleep in the supine position, there has been
an increase in cases of posterior positional plagio-
cephaly. Even though this condition is a purely
cosmetic problem, if it is severe it may affect the
child psychologically. Positioning may help in mild
or moderate cases, but more active treatment may
be necessary in severe cases.
Methods: A prospective study of 260 children
treated by dynamic orthotic cranioplasty for pos-
terior positional plagiocephaly was conducted in
Lausanne from 1995 to 2001. Construction of
these cranial remodelling helmets is decribed in
detail.
Results: The treatment lasted 3 months on av-
erage, was effective, well tolerated, and had zero
morbidity. The ideal period for initiating this ther-
apy is between the ages of 4 and 6 months.
Conclusion: The remodelling helmet is a con-
vincing option which can be recommended in in-
fants with posterior positional plagiocephaly
whose skull deformity is not satisfactorily cor-
rected by physiotherapy. It should always be used
before surgery is considered for patients with
recognised positional plagiocephaly in the first
year of life.
Key words: positional plagiocephaly; helmet; or-
thotic cranioplasty
In 1992 the American Academy of Pediatrics
(AAP), on the basis of a multinational investiga-
tion, established a direct correlation between
prone sleeping position and the incidence of sud-
den infant death syndrome [1]. In this report the
AAP recommended that infants be henceforth po-
sitioned to sleep either on the back or side. After
this publication and the subsequent “Back to Sleep
Campaign” [2], an increasing number of children
with craniofacial deformities was observed. Fol-
lowing an initial period of diagnostic and surgical
roaming in which surgical management had in-
creased to epidemic proportions [3], it became
obvious that this abnormal skull shape was not the
result of craniosynostosis, which is the premature
fusion of cranial sutures, but rather the conse-
quence of unrelieved pressure on the occiput dur-
ing infant sleep. This cranial deformity was called
posterior positional plagiocephaly (PPP). In about
two thirds of cases it may correct spontaneously
after regular changes in sleeping position or fol-
lowing physiotherapy aimed at correcting neck
muscle imbalance [4, 5]. In severe cases which fail
to improve despite counterpositioning treatment,
the hazards of surgical correction may be avoided
by cranial remodelling orthosis, originally de-
scribed in 1979 [6, 7] and more extensively em-
ployed in the nineties [8, 9]. The purpose of this
paper is to review our experience in treating chil-
dren with posterior positional plagiocephaly by
dynamic orthotic cranioplasty.
Summary
No financial
support declared.
Introduction
368
Original article SWISS MED WKLY 2007;137:368–372 · www.smw.ch
Peer reviewed article
SWISS MED WKLY 2007;137:368–372 · www.smw.ch 369
From March 1995 to November 2001, 260 children
presenting with PPP were consecutively treated by dy-
namic orthotic cranioplasty. They were initially examined
by the senior authors at the Paediatric Neurosurgery
Clinic of Lausanne University Hospital, Switzerland
(CHUV). Only patients with obvious cranial deformation
were proposed for a cranial remodelling helmet. For mild
cases, parents were reassured and instructed to place the
bulging side of their infant’s head toward the crib mattress.
Physiotherapy was proposed where appropriate. In every
child anthropometric measurements were taken, includ-
ing head circumference, distance from external auditory
meatus to external canthus (EAM – EC) and fronto-occip-
ital (FO) diagonals (Fig. 1). In unilateral posterior posi-
tional plagiocephaly there is typically an occipito-parietal
flattening, ipsilateral to this flattening the ear is anteriorly
displaced, and frontal bossing is observable. The ipsilat-
eral external auditory meatus to external canthus distance,
as well as the diagonal measured from the occipital flatten-
ing to the contralateral forehead, are therefore shorter
than their contralateral counterparts (Fig 1, lines A and B).
In a vertex view, the head exhibits the shape of a parallel-
ogram.
All cranial remodelling helmets were made in the Ergo-
therapy Service of the Hôpital Orthopédique de la Suisse
Romande, Lausanne, Switzerland. These orthoses are
thermoplastic constructs consisting of a semi-rigid styrene
outer shell thermobonded to a polyurethrane foam inner
lining (Polyform, Smith & Nephew, Germantown, USA).
The first step was to cover the infant’s head with a jersey
sock in order to make a plaster of Paris impression (Fig. 2
– left). This impression is then filled with plaster to create
a positive cast which is afterward corrected by applying a
crescent-shaped silicone module over the occipital flatten-
ing. A cranial remodelling orthosis is then created over this
corrected cast (Fig 2 – centre). A few days later the helmet
is applied to the infant (Fig. 3). Pressure is directed to con-
strain growth at the ipsilateral frontal and contralateral
parieto-occipital bulging, whereas a cavity is created over
the adjacent flattened area to promote remodelling. The
Patients and methods
Results
From March 1995 to November 2001, 260 in-
fants (63 girls and 197 boys) were consecutively
treated with a cranial orthosis for PPP in the Hôpi-
tal Orthopédique de la Suisse Romande, Lau-
sanne, Switzerland. Most of the patients had been
unsuccessfully treated by osteopathy and/or phys-
iotherapy before referral to the CHUV Paediatric
Nuerosurgery Clinic. Mean age at the beginning
of treatment was 6.1 ± 2.0 months (range: 3–18
months). As demonstrated in table 1, there was a
progressive increase in the number of cases treated
during the period of study.
There were 117 children with right-sided pos-
terior plagiocephaly (45%), 100 with left-sided
(38%), and only 43 with a bilateral form, without
lateralisation of the occipital flattening (17%). On
examination there were 36 infants (14%) showing
a contraction of the sternocleidomastoid muscle,
contralateral to the side of posterior plagiocephaly.
Most of the patients, however, even in the absence
Figure 1
Right posterior positional plagiocephaly. Vertex view of the
head. Right occipital flattening (arrow). Short (A) and long
(B) fronto-occipital diagonals.
Figure 2
Plaster of Paris im-
ression from the in-
fant’s head covered
with a jersey sock.
helmet was worn progressively during the first week of
treatment up to 21 hours a day. Every 2–3 weeks, the chil-
dren were followed up in the Ergotherapy Service for ad-
justment of the orthoses where necessary. In addition, the
patients were reevaluated at the end of the treatment by
the senior authors. At every examination anthropometric
measurements were repeated. Data are presented as the
mean ± SD. Statistical comparisons were performed by the
Student paired ttest analysis. Significant differences were
reported when the p value was <0.05.
Positional plagiocephaly, infant, helmet, dynamic orthotic cranioplasty 370
therapy was initiated before 6 months of age its
mean duration was 12 ± 6 weeks, and 13 ± 10 weeks
when patients were aged over 6 months at treat-
ment onset. This difference was not statistically
significant.
The results were subjectively considered good
by the parents and the investigators (Fig. 4). Ob-
jectively, this favourable impression was confirmed
by anthropometric measurements showing sym-
metrisation of the ipsilateral and contralateral
EAM – EC distances as well as FO diagonals.
Therefore, the ratios of these left and right dis-
tances and diagonals rapidly tend toward 1.0. In-
deed these ratios improved to statistically signifi-
cant levels after as little as 1 month of treatment
(figures 1 and 2).
In this series good results were obtained with
a single helmet in 147 patients, whereas 98 and 15
infants required 2 and 3 cranial orthoses respec-
tively. The cranial orthosis did not restrict cranial
growth, since serial head circumference measure-
ments showed that every patient remained on his
usual percentile curve.
Figure 3
Side view of an in-
fant wearing a cranial
remodelling helmet.
1995 1996 1997 1998 1999 2000 2001
N (girls/boys) 15 (3/12) 20 (0/20) 14 (0/14) 38 (8/30) 44 (13/31) 50 (17/33) 79 (22/57)
Mean age at treatment onset (months) 5.8 7.1 5.1 6.2 6.0 6.1 6.0
Mean duration of treatment (weeks) 21 18 17 15 12 12 9
Mean number of helmets used per child 1.4 1.5 1.6 1.8 1.6 1.7 1.2
Table 1
Epidemiology of
patients treated with
cranial remodelling
orthosis in Lausanne
from 1995 to 2001.
Figure 4
A. Pretreatment ver-
tex view of the head
of a 4-month-old in-
fant with right poste-
rior positional plagio-
cephaly. B. Results
after 2 months of
treatment by cranial
orthosis.
AB
Discussion
Etymologically, the term “plagiocephaly” has
Greek roots, “plagios” meaning “oblique” and
“kephale” head. One cause of plagiocephaly is
craniosynostosis, which is premature fusion of the
cranial suture(s). The skull shape can be predicted
from the suture(s) involved. Early fusion of the
lambdoid suture(s), which separate the parietal
from the occipital bones, causes posterior plagio-
cephaly. However, premature lambdoidal fusion is
extremely rare: whereas the overall incidence of
craniosynostosis is 6 per 10,000 live births, plagio-
cephaly secondary to isolated lambdoid premature
of clear-cut torticollis, had a tendency to turn the
head preferentially on one side, as previously de-
scribed [10].
Average duration of treatment was 13 ± 8
weeks (range: 4–31 weeks). There was a tendency
toward shorter treatment over the years. When
SWISS MED WKLY 2007;137:368–372 · www.smw.ch 371
fusion occurs in only 3 cases per 100,000 births
[11–13]. In contrast, over the past decade there has
been an increasing incidence of PPP [14, 15] which
has been reported in up to 48% of live births [11,
16]. It is important to distinguish lambdoid cran-
iosynostosis from PPP, because the course and the
management of these two conditions are clearly
different. True synostosis is habitually present
from birth, and is progressive. It never improves
spontaneously and carries the risk of intracranial
hypertension, although this occurs in less than
10% of cases when only a single suture is involved
[17]. In contrast, PPP is usually absent at birth, de-
velops during the first months of life, and carries
no risk of increased intracranial pressure.
Regarding the pathophysiological mechanism
of PPP, it is accepted that external forces applied
consistently to a specific region of the infant’s head
deform the skull. This explains why the increasing
incidence of babies presenting with occipital flat-
tening has coincided with current advice to posi-
tion infants to sleep in the supine position to pre-
vent sudden infant death syndrome [12, 14, 15].
Other pre- and postnatal factors, though rarer,
may favour the development of PPP by external
constraint. They include multiple births, de-
creased amniotic fluid, macrocephaly, malformed
uterus, congenital torticollis, cervical spine anom-
aly or brain injury with asymmetrical spasticity [7,
11, 15, 16, 18–20]. In these situations the cranial
deformity is usually present from birth and wors-
ens over the following weeks.
Simple clinical examination is usually suffi-
cient to diagnose postural posterior plagiocephaly
[11]. In vertex view, patients presenting with PPP
exhibit a parallelogram-shaped head: there is a flat-
tening of one side of the posterior cranium, along
with contralateral parieto-occipital and ipsilateral
frontal bossing, and the ipsilateral ear is displaced
anteriorly. In contrast, in unilateral lambdoid syn-
ostosis, the vertex view reveals a trapezium-shaped
head: there is unilateral occipitoparietal flattening
associated with contralateral frontal bossing. In
addition, the area of the fused lambdoid suture
presents as a bony ridge, with a bony prominence
in the mastoid region behind the ear, which is dis-
placed posteriorly and inferiorly [21]. Normally
there is no need for complementary radiological
investigations. In this study, neither CT scans nor
plain x-rays were done routinely. However, several
patients referred to our clinic had already had skull
x-rays done elsewhere. In this situation skull x-rays
reveal a sclerotic margin parallel to a patent lamb-
doid suture on the side of the occipital flattening
(Fig. 5). This aspect, sometimes called “lazy lamb-
doid”, must not be confused with a true lambdoid
synostosis where the suture is no longer visible
[22].
This study confirms some characteristic fea-
tures of PPP: three quarters of the patients were
boys, and there were a majority of infants with
right-sided plagiocephaly. A male preponderance
in up to 73% of cases and a right/left preference in
a proportion of 2:1 are also reported in the litera-
ture [4, 9, 10, 14, 16, 19, 22–25].
The natural history of PPP is difficult to es-
tablish in the absence of reliable and reproducible
data which would allow grading of its severity. It
has however been reported that over 70% of cases
improve spontaneously [4]. This improvement
may be encouraged by regular changes in sleeping
position and/or physiotherapy [4, 25, 26]. Severe
positional skull deformations may not always cor-
rect satisfactorily [6, 15, 27]. Even though there is
little information about the true risks of leaving
this condition untreated [11], PPP is probably es-
sentially a cosmetic problem of no significant neu-
rological consequence [4, 15, 27]. The role of the
various therapeutic modalities must therefore be
determined. In the nineties, when this condition
was emerging, surgical management was carried to
epidemic proportions [3, 4] until cranial remodel-
ling helmets were developed [8, 9]. This treatment
by orthotics was inspired by ancestral ethnic prac-
tices once aimed at intentionally deforming chil-
dren’s skulls [28].
This study shows that cranial remodelling or-
thosis is a valuable treatment option for infants
whose PPP is not satisfactorily corrected by phys-
iotherapy. The earlier the helmet is applied, the
more rapid and complete will be the correction [9,
11, 14, 24]. In practice, the ideal period for initiat-
ing this treatment is from 4 to 6 months of age. At
this age, in our series, the treatment duration av-
Figure 5
Skull x-rays of a
5-month-old baby
with left posterior po-
sitional plagio-
cephaly. A. AP view
showing patent radi-
olucent lambdoid su-
tures. Note the scle-
rotic margin (arrows)
parallel to the left
lambdoid suture,
on the side of the
occipital flattening.
B. Lateral view. The
sclerotic margin is
also visible (arrows).
AB
eraged 3 months. Before 4 months of age, experi-
ence has shown that the infants usually do not have
enough cervical muscle strength to tolerate the
helmet. After 1 year of age, because cranial growth
lessens and the skull thickens, correction by ortho-
sis is longer and less impressive. In addition, older
children tend to remove their helmets themselves
as they do not tolerate them as well as younger
ones. In practice, we do not usually propose treat-
ment after 1 year of age except as an ultimate at-
tempt to avoid surgical correction. Convincing re-
sults in such rare cases have however been reported
in a small series [29].
Conclusion
This study shows that treatment by cranial re-
modelling orthosis is effective, well tolerated, and
has zero morbidity. It can be recommended in in-
fants with PPP whose skull deformity is not satis-
factorily corrected by physiotherapy. This thera-
peutic option should always be taken up before sur-
gery is considered for patients with recognised
PPP in the first year of life, bearing in mind that
this type of surgery would be a cosmetic procedure
frequently requiring blood transfusion and not
without risk in view of the proximity of posterior
dural sinuses.
Correspondence:
Dr S. de Ribaupierre
Service of Neurosurgery
Centre Hospitalier Universitaire Vaudois
Rue du Bugnon 46
CH-1011 Lausanne
Switzerland
E-Mail: s_derib@hotmail.com
References
1 American Academy of Pediatrics. AAP Task Force on Infant Po-
sitioning and SIDS: positioning and SIDS. Pediatrics. 1992;89:
1120–6.
2 Havens DH, Zink RL. The “Back to Sleep” campaign. J Pedi-
atr Health Care. 1994;8:240–2.
3 Ortega B. Unkind cut. Some physicians do unnecessary surgery
on heads of infants. They remold lopsided skull when a correc-
tive band may be all that’s necessary. Wall Street Journal. Feb-
ruary 23, 1996.
4 Jones BM, Hayward R, Evans R, Britto J. Occipital plagio-
cephaly: an epidemic of craniosynostosis. Craniosynostosis
needs to be distinguished from more common postural asym-
metry. BMJ. 1997;315:693–4.
5 Hellbusch JL, Hellbusch LC, Bruneteau RJ. Active counter-po-
sitioning treatment of deformational occipital plagiocephaly.
Nebr Med J. 1995;80:344–9.
6 Clarren SK, Smith DW, Hanson JW. Helmet treatment for pla-
giocephaly and congenital muscular torticollis. J Pediatr.
1979;94:43–6.
7 Clarren SK. Plagiocephaly and torticollis: etiology, natural his-
tory, and helmet treatment. J Pediatrics. 1981;98:92–5.
8 Ripley CE, Pomatto J, Beals SP, Joganic EF, Manwaring KH,
Moss AD. Treatment of positional plagiocephaly with dynamic
orthotic cranioplasty. J Craniofacial Surg. 1994;5:150–60.
9 Littlefield TR, Beals SP, Manwaring KH, Pomatto JK, Joganic
EF, Golden KA, et al. Treatment of craniofacial asymmetry with
dynamic orthotic cranioplasty. J Craniofac Surg. 1998;9:11–7.
10 Golden KA, Beals SP, Littlefield TR, Pomatto JK. Sternoclei-
domastoid imbalance versus congenital muscular torticollis:
their relationship to positional plagiocephaly. Cleft Palate
Craniofac J. 1999;36:256–61.
11 Rekate HL. Occipital plagiocephaly: a critical review of the
literature. J Neurosurg. 1998;89:24–30.
12 Shuper A, Merlob P, Grunebaum M, Reisner SH. The incidence
of isolated craniosynostosis in the newborn infant. Am J Dis
Child. 1985;139:85–6.
13 French LR, Jackson IT, Melton LJ III. A population-based study
of craniosynostosis. J Clin Epidemiol. 1990;43:69–73.
14 Argenta LC, David LR, Wilson JA, Bell WO. An increase in in-
fant cranial deformity with supine sleeping position. J Cranio-
fac Surg. 1996;7:5–11.
15 Kane AA, Mitchell LE, Craven KP, Marsh JL. Observations on
a recent increase in plagiocephaly without synostosis. Pedi-
atrics. 1996;97:877–85.
16 Watson GH. Relation between side of plagiocephaly, disloca-
tion of hip, scoliosis, bat ears, and sternomastoid tumours. Arch
Dis Child. 1971;46:203–10.
17 Gault DT, Renier D, Marchac D, Jones BM. Intracranial pres-
sure and intracranial volume in children with craniosynostosis.
Plast Reconstr Surg. 1992;90:377–81.
18 Littlefield TR, Kelly KM, Pomatto JK, Beals SP. Multiple-birth
infants at higher risk for development of deformational plagio-
cephaly. Pediatrics. 1999;103:565–9.
19 Slate RK, Posnick JC, Armstrong DC, Buncic JR. Cervical spine
subluxation associated with congenital muscular torticollis and
craniofacial asymmetry. Plast Reconstr Surg. 1993;91:1187–95.
20 Tinuper P, Plazzi G, Provini F, Cerullo A, Leonardi M, et al.
Facial asymmetry in partial epilepsies. Epilepsia. 1992;33:1097–
100.
21 Huang MH, Mouradian WE, Cohen SR, Gruss JS. The differ-
ential diagnosis of abnormal head shapes: separating craniosyn-
ostosis from positional deformities and normal variants. Cleft
Palate Craniofac J. 1998;35:204–11.
22 Pople IK, Sanford RA, Mulbauer MS. Clinical presentation and
management of 100 infants with occipital plagiocephaly. Pedi-
atr Neurosurg. 1996;25:1–6.
23 Dias MS, Klein DM, Backstrom JW. Occipital plagiocephaly:
deformation or lambdoid synostosis? I. Morphometric analysis
and results of unilateral lambdoid craniectomy. Pediatr Neuro-
surg. 1996;24:61–8.
24 Kelly KM, Littlefield TR, Pomatto JK, Ripley CE, Beals SP,
Joganic EP. Importance of early recognition and treatment of
deformational plagiocephaly with orthotic cranioplasty. Cleft
Palate Craniofac J. 1999;36:127–30.
25 Kelly KM, Littlefield TR, Pomatto JK, Manwaring KH, Beals
SP. Cranial growth unrestricted during treatment of deforma-
tional plagiocephaly. Pediatr Neurosurg. 1998;30:193–9.
26 Moss DS. Nonsurgical, nonorthotic treatment of occipital pla-
giocephaly: what is the natural history of misshapen neonatal
head? J Neurosurg. 1997;87:667–70.
27 Danby PM. Plagiocephaly in some 10-year-old children. Arch
Dis Child. 1962;37:500–4.
28 Gerszten PC, Gerszten E. Intentional cranial deformation:
a disappearing form of self-mutilation. Neurosurgery. 1995;37:
374–82.
29 Littlefield TR, Pomatto JK, Kelly KM. Dynamic orthotic cran-
ioplasty: treatment of the older infant. Report of four cases.
Neurosurg Focus. 2000;9:1–4.
372
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... 9,10) Therefore, parents have become increasingly attentive to their infants' head shape, leading to a surge in pediatrician visits. 11,12) However, few studies have investi gated the treatment of positional plagiocephaly, and there is limited evidence regarding the effectiveness of helmet therapy for infants with this condition. Therefore, the treatment for positional plagiocephaly primarily depends on clinical experience and varies greatly. ...
... Despite some disagreement, most studies reported that helmet therapy is effective in improving and preventing the progression of positional plagiocephaly. [9][10][11][12] According to recent reports, the effectiveness of helmet therapy is influenced primarily by the age at which the therapy is initiated and the severity of the asymmetry. 19,20,26) Moreover, it has been reported that the earlier the helmet is applied, the more rapid and complete the correction will be. ...
... 6) Some studies have suggested that helmet therapy initiated before 6 months of age is preferable. 11,15) However, infants younger than 4 months old usually lack the cervical muscle strength to tolerate the helmet. 11) In contrast, helmet therapy after 1 year of age is generally less effective because the skull thickens and cranial growth slows down. ...
Article
Background: The use of helmet treatment for positional plagiocephaly has increased recently; however, its effect is unknown in Korea. Purpose: This study aimed to investigate the effectiveness of helmet therapy and identify its influencing factors. Methods: Ninety pediatric patients diagnosed with moderate to severe positional plagiocephaly received helmet therapy. Severity of moderate to severe positional plagiocephaly was defined as cranial vault asymmetry (CVA) >10 mm or CVA index (CVAI) >6%. Patients were categorized by age, severity, and daily helmet wear. Multiple regression analysis controlled for factors like sex and prematurity. Treatment success was assessed by comparing pre/post-helmet theray CVA and CVAI, considering normalization or decrease to mild plagiocephaly (CVA ≤10 mm or CVAI ≤6%). Results: A total of 90 participants were enrolled (mean age, 5.6±1.6 months; male, 53 [58.9%]). The mean helmet therapy duration was 6.4±2.7 months, while the mean daily wear time was 18.4±2.7 hours. Among the 90 patients, 66 (73.3%) had moderate disease and 24 (26.7%) had severe disease. The mean CVA and CVAI decreased by 6.3±2.7 mm and 4.3%±1.8% after versus before treatment (P<0.001). Treatment was successful in 76 infants (84.4%). The most effective changes in CVA and CVAI were noted in those who began treatment before 9 months of age (6.2±2.5 mm and 5.0%±1.9%, P<0.001), had high compliance (6.2±2.4 mm and 4.9%±1.9%, P<0.001), and had high severity (8.0±2.3 mm and 6.6%±1.7%, P<0.001). Conclusion: Starting helmet treatment before 9 months and wearing it over 15 hours daily yielded better outcomes.
... Lagerungsbedingte Kopfasymmetrien treten bei männlichen Säuglingen deutlich häufiger auf [10,30,31,[48][49][50][51][52][53][54]. In der Literatur wird das Verhältnis von männlichen zu weiblichen Patienten zwischen 3:1 und 3:2 angegeben [39,48,52,[55][56][57]. ...
... Die Effektivität der HT wurde in der Literatur umfänglich bestätigt. So kann bei guter Mitarbeit der Patienten und Eltern sowohl eine signifikante Reduktion der subjektiv wahrnehmbaren Schädelasymmetrie [11,186,187,198,206,208] als auch der objektiv messbaren Asymmetrie festgestellt werden [28, 39,50,55,128,136,139,140,190,[192][193][194][195][196][209][210][211][212][213][214][215]. In einigen Studien konnte des Weiteren eine Reduktion der Ohrachsenasymmetrie (ear shift) nachgewiesen werden [138,145,146]. Lee et al. ...
Thesis
Der lagerungsbedingte Plagiozephalus (LP) stellt die häufigste Schädeldeformation bei Kleinkindern dar. Ursachen, Risikofaktoren und die Wirksamkeit konservativer Therapieverfahren wurden in einer Vielzahl von Veröffentlichungen dargestellt. Untersuchungen zur Langzeitstabilität des Helmtherapieerfolges und die Auswirkungen eines LP auf das stomatognathe System bei Kleinkindern sind hingegen selten. Die vorliegende kontrollierte, prospektive Längsschnittstudie stellt die erste 3D- Untersuchung dar, die belegt, dass die Kopforthesentherapie bei Patienten mit LP zu besseren Langzeitergebnissen im Vergleich zu anderen Therapieoptionen führt. Auch nach Abschluss der Kopforthesentherapie ist eine weitere Verbesserung der Kopfform zu beobachten. Bei Patienten mit LP besteht zudem grundsätzlich ein höheres Risiko für laterale Kreuzbisse, die bevorzugt auf der kontralateralen Seite in Relation zur abgeflachten Hinterhauptseite auftreten. Gesichtsasymmetrien treten häufiger bei Patienten mit LP auf, bei denen keine Kopforthesentherapie durchgeführt wurde. Folglich stellt die Kopforthesentherapie eine geeignete Therapieoption für Säuglinge mit LP dar, um sowohl die Schädelasymmetrie als auch das Auftreten dentofazialer Asymmetrien zu reduzieren.
... The headband covers the entire head, except for the top of the head. Regardless of the design, customized head braces for patients are made from high-temperature thermoplastic material (Surlyn, Dupont, Wilmington, DE, USA) using high density hypoallergenic medical grade foam (Fig. 2) [26,[34][35][36]. First, the head of the patient is scanned with a 3D laser to create a head model. ...
... As the patient' s skull grows, the growth of the protruding part of the head is limited, while the extra space around the flat portion of the head allows for more growth towards the relatively less flat part of the head with less resistance [37]. Some studies suggest that faster correction can be achieved by applying pressure on the protruding portion of the head, which is actively growing [34][35][36][37][38][39]. ...
Article
Full-text available
Positional plagiocephaly is increasing in infants. Positional plagiocephaly is an asymmetric deformation of skull due to various reasons; first birth, assisted labor, multiple pregnancy, prematurity, congenital muscular torticollis and position of head. Positional plagiocephaly can mostly be diagnosed clinically and by physical examinations. The simplest way to assess the severity of plagiocephaly is to use a diagonal caliper during physical examination, which measures the difference between the diagonal lengths on each side of the head. Plagiocephaly can be treated surgically or conservatively. Positional plagiocephaly, which is not accompanied by craniosynostosis, is treated conservatively. Conservative treatments involve a variety of treatments, such as change of positions, physiotherapy, massage therapy, and helmet therapy. Systematic approaches to clinical examination, diagnosis and treatment of positional plagiocephaly can be necessary and the age-appropriate treatment is recommended for patients with positional plagiocephaly.
... Deformational plagiocephaly (DP) is a common condition in infants that can cause craniofacial abnormalities [25], which has become more common since the 1990s "Back-to-Sleep" initiative to prevent sudden infant death syndrome (SIDS) [43][44][45]. Most experts recommend DP treatment with cranial orthoses, namely helmet-molding therapy, at 4 to 6 months of age [46][47][48][49]. However, a natural course of craniofacial symmetry from our study may provide a suggestion of observation only for those infants with mild plagiocephaly instead of helmet treatment. ...
Article
Full-text available
Objective: To evaluate the development of the craniofacial region in healthy infants and analyze the asymmetry pattern in the first year of life. Methods: The participants were grouped by sex and age (1, 2, 4, 6, 9, and 12 months) to receive three-dimensional (3D) photographs. Stereoscopic craniofacial photos were captured and transformed into a series of craniofacial meshes in each group. The growth patterns of the anthropometric indices and the degree of craniofacial asymmetry were measured, and average craniofacial meshes and color-asymmetry maps with craniofacial asymmetry scores were calculated. Results: A total of 373 photographs from 66 infants were obtained. In both genders, the highest and lowest growth rates for all anthropometric indices were noted between 1 and 2 months and between 9 and 12 months, respectively. Overall, male infants had higher anthropometric indices, head volume, and head circumference than female infants. The craniofacial asymmetry score was presented with a descending pattern from 1 to 12 months of age in both sex groups. Both sex groups showed decreased left-sided laterality in the temporal-parietal-occipital region between 1 and 4 months of age and increased right frontal-temporal prominence between 6 and 12 months of age. Conclusions: A longitudinal evaluation of the craniofacial growth of healthy infants during their first year of life was presented.
... Die sogenannten Helme liegen dabei an den prominenten Bereichen des Kopfes passiv an, wodurch an diesen Stellen das weitere Wachstum eher gehemmt wird.Gleichzeitig besteht an den abgeflachten Arealen ein Freiraum zwischen dem Säuglingsschädel und der Kopforthese, sodass das weitere Wachstum sich besonders in diesen Arealen abspielt[6,57,71,136].Kopforthesen werden von verschiedenen Herstellern angeboten, wobei dasDesign meist sehr ähnlich und das grundsätzliche Funktionsprinzip gleich ist[12]. In den meisten Fällen bestehen die Helme aus thermoplastischen Kunststoffen, die mit einem hypoallergenen, medizinischen Schaum ausgekleidet sind[89,115] und ein geringes Eigengewicht von etwa 150-180g aufweisen[137].Im Verlauf der Therapie wird die Kopforthese im Rahmen der regelmäßigenKontrolluntersuchungen durch individuelle Einschleifmaßnahmen an denWachstumsverlauf angepasst[97,138]. Wie bereits dargestellt kann durch die Ausnutzung des körpereigenen Wachstums eine Harmonisierung der Kopfform erreicht werden[139]. ...
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.
... A subsequent study showed that 54 children (26.3%) had minor adverse events during the course of cranial-molding orthotic treatment, which included pressure sores (13.7%), ethanol erythema (2.9%), skin erosion/skin infection (4.3%), or improper fit (5.4%) [20]. A large prospective study of 260 patients who were treated with custom cranial-molding orthoses reported a morbidity rate of 0% [21]. Another prospective study reported that all infants had one or more adverse events related to cranial-molding orthoses: problems with acceptance of the helmet (24%), skin irritation (96%), increased sweating (71%), unpleasant odor of the helmet (76%), pain associated with the helmet (33%), and parents' feeling hindered from cuddling their child (77%) [10]. ...
Article
Full-text available
Objective: To investigate the clinical effectiveness of and parents' perspectives on cranial-molding orthotic treatment. Methods: Medical charts were reviewed for 82 infants treated for plagiocephaly with cranial-molding orthoses in our clinic from April 2012 to July 2016 retrospectively. Infants who were clinically diagnosed with positional plagiocephaly and had a Cranial Vault Asymmetry Index (CVAI) of more than 3.5% were included. Pre- and post-treatment CVAI was obtained by three-dimensional head-surface laser scan. Parents' perceptions of good outcome (satisfaction) were evaluated with the Goal Attainment Scale (GAS). The GAS score assessed how much the parent felt that his or her initial goal for correcting the skull asymmetry was achieved after the treatment. Results: The compliance with cranial-molding orthoses was 90.2% (74 of 82 infants). There were 53 infants (65% of the 82 infants) who had adverse events with the cranial-molding orthoses during the study. Heat rash was found in 29 cases (35.4%) and was the most common adverse event. The mean GAS T-score was 51.9±10.2. A GAS T-score of 0 or more was identified for 71.6% of parents. The GAS T-score was significantly related to the age (p<0.001), the initial CVAI, and the difference of CVAI during the treatment (p<0.001). Conclusion: Parents' perception of good outcome was correlated with the anthropometric improvement in cranialmolding orthotic treatment in infants with plagiocephaly. A high percentage of parents felt that the treatment met their initial goals in spite of a high occurrence of adverse events.
Article
Plagiocephaly is a common deformity of the skull. Various treatment approaches have been used for the subjects with head deformities, including use of helmet orthosis, repositioning, exercise, and only observation. The aim of this review was to check the efficiency of helmet therapy compared to other available approaches and also to check the effects of some parameters such as the duration of use, and age of the subjects on treatment of the subjects with this deformity. A search was done in some databases, including Google scholar, ISI Web of knowledge, PubMed, and Scopus. Some keywords such as plagiocephaly, posterior plagiocephaly, and occipital plagiocephaly were used in combination with positional modeling, helmet therapy, helmet orthosis, exercise, and observation. The quality of the studies was evaluated by use of Down and Black tool. Twenty-four studies were found on the mentioned keywords. The quality of the studies varied between 11 and 21. Although the efficiency of helmet therapy was more than other treatment approaches, the final outputs depend on optimal time and deformity criteria. This approach is effective, well tolerated with no morbidity. Moreover, it does not influence on the quality of life of the subjects. The efficiency of helmet therapy to correct head deformities is more than other available approaches. However, its effects depend on the age of the subjects at onset of treatment, duration of treatment, and severity of the deformity. Any side effects of this treatment method can be decreased by proper education of the subjects.
Article
Objectives: To study the effects of infantile positional plagiocephaly on the growth and neural development. Methods: A retrospective study was conducted on the medical data of 467 children who underwent craniographic examination and were followed up to 3 years of age in Peking University Third Hospital from June 2018 to May 2022. They were divided into four groups: mild positional plagiocephaly (n=108), moderate positional plagiocephaly (n=49), severe positional plagiocephaly (n=12), and normal cranial shape (n=298). The general information of the four groups and the weight, length, head circumference, visual acuity screening results, hearing test results, and the scores of Pediatric Neuropsychological Developmental Scales/Gesell Developmental Schedules of the four groups from 6 to 36 months old were compared. Results: The rates of adverse perinatal factors, congenital muscular torticollis, and supine fixed sleeping posture in the mild, moderate, and severe positional plagiocephaly groups were higher than the normal cranial group (P<0.05). There was no significant difference in weight, length, and head circumference among the four groups at 6, 12, 24 and 36 months of age (P>0.05). The incidence rate of abnormal vision in the severe positional plagiocephaly group was higher than that in the mild positional plagiocephaly, moderate positional plagiocephaly and normal cranial shape groups at 24 and 36 months of age (P<0.05). The scores of the Pediatric Neuropsychological Developmental Scales at 12 and 24 months of age and the scores of the Gesell Developmental Schedules at 36 months of age in the severe positional plagiocephaly group were lower than those in the mild positional plagiocephaly, moderate positional plagiocephaly and normal cranial shape groups, but the difference was not statistically significant (P>0.05). Conclusions: Adverse perinatal factors, congenital muscular torticollis, and supine fixed sleeping position may be associated with infantile positional plagiocephaly. Mild or moderate positional plagiocephaly has no significant impact on the growth and neural development of children. Severe positional plagiocephaly have adverse effects on the visual acuity. However, it is not considered that severe positional plagiocephaly can affect the neurological development.
Thesis
Die vorliegende Arbeit ist in das interdisziplinäre Forschungsprojekt „Dreidimen-sionale stereophotogrammetrische Diagnostik des Schädels und Evaluierung der Therapie bei Kindern mit kraniofazialen Fehlbildungen“ (CFCW-Gesamtprojekt) am Universitätsklinikum Würzburg eingebettet. Gefördert wurde das Projekt durch das Interdisziplinäre Forschungszentrum für Klinische For-schung (IZKF) des Universitätsklinikums Würzburg. Vorliegende Untersuchung erfolgte im Teilprojekt „Sprache“ des CFCW-Gesamtprojektes am Zentrum für vorsprachliche Entwicklung und Entwick-lungsstörungen (ZVES) an der Poliklinik für Kieferorthopädie und hatte das Ziel, temporale Eigenschaften von Komfortlauten zu untersuchen. Verglichen wurden Vokalisations- und Segmentierungslängen von Komfortlau-ten von Säuglingen mit (PG) bzw. ohne (KG) einen lagerungsbedingten Plagio-zephalus im Alter von 6 Monaten. Ein lagerungsbedingter Plagiozephalus kommt durch wiederholte Krafteinwir-kungen externer Kräfte (Lagerung) auf eine Seite des Hinterkopfes zustande. Durch diese Krafteinwirkung ist in den ersten Lebensmonaten eine Verformung des noch einfach zu verformenden Säuglingsschädels möglich. Es gibt Hinweise darauf, dass ein lagerungsbedingter Plagiozephalus kein rein ästhetisches Problem ist, sondern mit einer Entwicklungsverzögerung in Zu-sammenhang stehen könnte. Vorliegende Arbeit untersucht daher, ob sich ein lagerungsbedingter Plagiozephalus auf die temporalen Eigenschaften der Pho-nation auswirkt. Im Rahmen des Teilprojektes „Sprache“ wurden spontan evozierte Komfortlaute von jeweils 33 Säuglingen mit bzw. ohne einen lagerungsbedingten Plagioze-phalus unter standardisierten Bedingungen aufgenommen und anhand einer festgelegten Routine im ZVES bearbeitet, analysiert und quantitativ verglichen. Die Komfortlaute wurden für die Analysen, abhängig von ihren rhythmischen Eigenschaften, in 4 Kategorien (siehe Kapitel 2.6) eingeteilt. Es konnten insgesamt 3470 Komfortlaute (KG: N = 1720; PG: N = 1750) für die Analysen herangezogen werden. Unabhängig von der ursprünglichen Gruppeneinteilung (KG/PG), die individuell durch die behandelnden Ärzte erfolgte, wurden die Probanden zusätzlich mittels des auf 3D-Scan-Daten beruhenden „Moss-Index“ (30°-Diagonalen-Differenz) neu eingeteilt, um den Einfluss der Kopfasymmetrie auf die Vokalisations- und Segmentierungslängen spezifisch beurteilen zu können. Ergebnis dieser Untersuchung ist, dass in allen durchgeführten Analyseschritten die Vokalisations- und Segmentierungslängen in der Plagiozephalusgruppe zwischen 8 % und 10 % länger waren als in der Kontrollgruppe. Dieser Unter-schied war allerdings statistisch nicht signifikant. Eine Verlängerung zeitlicher Regelprozesse in der Phonation geht mit verzögerten Verarbeitungsprozessen der auditiven Wahrnehmung akustischer Signale einher. Die Untersuchung stellt die Hypothese für nachfolgende Untersuchungen auf, dass die Analyse tempo-raler Messgrößen ein geeignetes Verfahren zur Identifikation von Risikokindern bereits im Säuglingsalter sein könnte, bei denen sich später eine Entwicklungs-verzögerung manifestieren könnte.
Article
The correct differential diagnosis of an abnormal head shape in an infant or a child is vital to the management of this common condition. Establishing the presence of craniosynostosis, which warrants surgical correction, versus non-synostotic causes of head deformity, which do not, is not always straightforward. This paper deals with three groups of abnormal head shape that may cause diagnostic confusion: the spectrum of metopic synostosis; the dolicho-cephaly of prematurity versus sagittal synostosis; and the differential diagnosis of plagiocephaly. Special emphasis has been placed on the problem of posterior plagiocephaly, in the light of recent evidence demonstrating that lambdoid synostosis has been overdiagnosed. Metopic synostosis presents as a wide spectrum of severity. Although only severe forms of the disorder are corrected surgically, all cases should be monitored for evidence of developmental problems. The dolichocephalic head shape of preterm infants is non-synostotic in origin and is managed nonsurgically. The scaphocephalic head shape resulting from sagittal synostosis requires surgical intervention for correction. Posterior plagiocephaly may be due to unilambdoid synostosis or positional molding, which have very different clinical and imaging features. True lambdoid synostosis is rare. Most cases of posterior plagiocephaly are due to positional molding, which can usually be managed nonsurgically. Regardless of the suture(s) involved, all children with confirmed craniosynostosis should be monitored for increased intracranial pressure and developmental problems.
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
Between 1987 and 1992, 30 infants aged 1.4–13 months (mean 7.3 months) underwent unilateral lambdoid strip craniectomy at the Children’s Hospital of Buffalo for occipital plagiocephaly. Males outnumbered females (22:8) and right-sided occipital flattening was significantly more common than left-sided flattening (25:5). The deformity was noticed at an average age of 3.2 months; 16% of the infants had an asymmetry at birth. Positional preferences (a distinct tendency to lie preferentially on the back, in most cases with the head turned to the ipsilateral side) were described in 79% of infants for whom this information was available, and torticollis was present in 10%. Pre- and postoperative CT scans were analyzed using several morphometric measurements. Asymmetries were measured between the flattened and contralateral sides, both posteriorly and anteriorly, using a translucent grid placed over the CT slice showing maximum asymmetry. The average maximum asymmetry between the flattened and contralateral sides was 24% posteriorly and 16% anteriorly. Significant improvements were seen postoperatively, with both anterior and posterior asymmetries improving by an average of one third (p < 0.05). However, when compared with CT scans from a control group of infants without synostosis, the operated group showed persistent and significant asymmetries postoperatively. The morphometric measurements described allow an objective and reproducible means of assessing the results of various treatments for this disorder. The improvements following unilateral lambdoid craniectomy are difficult to interpret in isolation; we suggest that future efforts be directed toward similarly assessing the results of both nonoperative treatments such as positional changes and molding helmets, and more aggressive surgical treatments that have been advocated for this disorder.
Article
Plagiocephaly usually originates in late fetal life through aberrant constraint of the fetal head and is often associated with sternocleidomastoid torticollis. In some patients the obligue head shape may become a permanent, cosmetic disability. Individually fitted plastic helmets, similar in style to football helmets, have been successfully used to remold the deformed heads of four infants. Each helmet is designed to fit snugly against the prominent aspects of the infants' cranium and to be loose fitting where the head is shallow. As the brain grows, the head is molded to fit the helmet and thus acquires a more usual shape. The treatment has been safe and effective. When torticollis is persistent after the initiation of treatment, rubber straps can be fixed to the outside of the helmet and attached to the side rails of the crib. While the infant sleeps, the straps can be tightened to stretch the shortened sternocleidomastoid muscle.
Article
Fifty-six consecutive epileptic patients with partial seizures (30 temporal, 26 extratemporal) and facial asymmetry were studied. Facial asymmetry was compared with EEG, radiologic, and other clinical findings. Thirty patients had a lesional epilepsy whereas 26 were considered cryptogenic. In lesional epilepsies, 60% of patients had EEG foci ipsilateral to the smaller hemiface and only 20% had EEG foci contralaterally. In the cryptogenic group, the EEG focus was ipsilateral in 50% and contralateral to the facial smallness in 46%. No differences were noted between temporal and extratemporal epilepsies. Early acquired cerebral lesions may modify development of the hemisphere involved, leading to a small ipsilateral hemiface and seizures originating from the same side.
Article
Intracranial volume and intracranial pressure have been measured in 66 children with craniosynostosis, 48 boys and 18 girls. The premature fusion of skull sutures is assumed to restrict skull growth and predispose to elevated intracranial pressure. Thirteen children (20 percent) had raised intracranial pressure and demonstrated a significant restriction of skull growth. In this series, volume measurement alone, however, did not serve as a reliable predictor that the intracranial pressure was raised.
Article
A population-based study of the incidence of craniosynostosis was conducted among residents of Olmsted County, Minnesota, born between 1 January 1976 and 31 December 1985. This study included only those with primary craniosynostosis who were less than 5 years of age at the time of diagnosis. Cases of craniosynostosis were classified as definite or probable. Definite cases had craniectomies or radiographic evidence confirming craniosynostosis, while patients for whom there was enough concern about craniosynostosis to order a skull radiograph were classified as probable cases. With these definitions, the incidence of craniosynostosis in Olmsted County was 3.1/10,000 births for definite cases (95% CI, 0.4-5.8) and 13.6/10,000 for all cases combined (95% CI, 7.9-19.3). These rates were compared to non-population-based minimal and maximal estimates of craniosynostosis frequency, 4/10,000 births and respectively. The rate observed in this study for definite cases, 3.1/10,000 births, is statistically consistent with the previous low estimate (observed/expected ratio 0.8, 95% CI, 0.2-1.8), and the rate observed for all cases in this study, 13.6, is consistent with the high estimate (observed/expected ratio 1.4, 95% CI, 0.8-2.1). Differences between definite and probable cases in this study are presented, along with comparisons with recent population-based data.
Article
The incidence of isolated, nonsyndromatic craniosynostosis in a newborn population was found to be 0.6 per 1,000 live births. The distribution by anatomic types was metopic suture, 50%; sagittal suture, 28%; coronal suture, 16.5%; and lambdoid suture, 5.5%. We found a higher incidence of trigonocephaly than has been reported previously.
Article
Watson, G. H. (1971). Archives of Disease in Childhood, 46, 203. The relationship between the side of plagiocephaly, dislocation of the hip, scoliosis, bat ears, and sternomastoid tumours. A relation is described between plagiocephaly and four structural lesions in children who have two or more of these five features. The flat temple in plagiocephaly, a unilateral congenitally dislocated hip, a scoliotic convexity in a young child, and a sternomastoid tumour tend to be on the same side, and a unilateral bat ear on the opposite side.