Evaluation and Treatment of Deformational

Transcription

Evaluation and Treatment of
Deformational Plagiocephaly &
Other Head Shape Deformities
www.STARbandkids.com
The “Epidemic” of Deformational
Plagiocephaly
The Back to Sleep Program is regarded as one of the most successful programs ever
initiated by the American Academy of Pediatrics. The rate of sudden infant death
in the United States has decreased over 40% since the program’s inception in 1992,
saving thousands of infants’ lives. Supine positioning for sleep, keeping the child cool
at night, discontinuing smoking at home, eliminating shared bed sleeping and using
a pacifier for naps and nighttime sleeping have been found to reduce the incidence
of sudden infant death. However, an unintended consequence of the program is
the increase in the number of infants who acquire skull deformities secondary to
extensive time spent on their backs at night coupled with an inappropriate amount of
time supine when the babies are awake. Fortunately, parents are now encouraged to
reduce the time in infant positioning devices and to place their babies prone as much
as possible when awake to prevent head shape deformities and to encourage normal
development.
Parents are naturally concerned if they observe asymmetry or unusual flat spots
on their baby's head, and often seek advice from their pediatrician. This guide is
designed to provide information about the causes, signs, and treatment strategies
for managing head shape deformities in
infants. Treatment interventions include
repositioning, a developmental home
program, physical therapy, and/or the use
of a cranial remolding orthosis, such as the
STARband®, to improve symmetry and
normal proportion.
©2015 Orthomerica Products, Inc.
1
Why are the Skulls of Infants Subject
to Deformation?
••
The plasticity of the newborn’s skull makes it susceptible to external pressures in the
womb, during the birth process, and after birth.
••
The immobility of newborns and any positional neck preference can predispose infants
to extrinsic skull deformities.
••
Intrinsic abnormalities can be caused by craniosynostosis or through
genetic transmission.
••
Deformational forces most frequently affect the occiput, although the frontal bones
and the face may be affected in severe cases.
••
About 24%* of babies have some type of noticeable skull deformity at birth, reducing
to about 20%† by 4 months of age.
••
The abnormal shape may persist if the baby spends most of the day on the back
against the hard surface of infant carriers and holding devices.
*Peitsch WK, Keefer CH et al. Incidence of Cranial Asymmetry in Healthy Newborns. Pediatrics 100:e72, 2002
†Hutchison BL, Hutchison AD. Plagiocephaly and Brachycephaly in the First Two Years of Life: A Prospective Cohort Study. Pediatrics: 114;970. 2004
2
What are Contributing Risk Factors for
Deformational Plagiocephaly?
••
Prolonged supine positioning.
••
Lack of time on the tummy when the baby is awake.
••
Congenital Muscular Torticollis, neck weakness or restricted neck range of motion.
••
Males more frequently develop deformational plagiocephaly at a rate of 2:1.
••
Slower motor development particularly in gross motor skills.
••
Breech or transverse presentation in utero.
••
Multiple birth infants.
••
Visual field deficits.
••
Bony abnormality in the cervical spine.
(Pictured above: torticollis and supine position are risk factors.)
3
What are the Types of Deformational
Head Shapes?
DEFORMATIONAL PLAGIOCEPHALY
••
The most common type of skull deformity in infants.
••
Normally noticed by caregivers at about 6 to 10 weeks of age.
••
Characterized by an asymmetrical skull shape.
••
Unilateral occipital flattening.
••
Ear is positioned more anterior on the side of the occipital flattening.
••
Forehead may be asymmetrical and is positioned more anterior on the side of the
occipital flattening.
••
Facial asymmetry may be present.
••
May be accompanied by torticollis, limited neck range of motion, weakness and
preferential head positioning.
4
DEFORMATIONAL BRACHYCEPHALY
••
Central occipital flattening.
••
Increased cranial vault height posteriorly. The head is excessively wide for its length.
••
May be accompanied by a prominent, bossed forehead.
DEFORMATIONAL BRACHYCEPHALY WITH ASYMMETRY
••
Combination of brachycephalic and plagiocephalic characteristics.
••
The shape is disproportionately wide for its length and is also asymmetrical.
••
May or may not include asymmetries to the forehead and facial structure.
5
DEFORMATIONAL SCAPHOCEPHALY
••
Very elongated head shape that is excessively long for its width.
••
May be accompanied by a prominent, bossed forehead.
••
Deformational Scaphocephaly caused by extrinsic forces is uncommon although it
is sometimes seen in premature infants who are often positioned side lying, such as
NICU infants.
••
Scaphocephaly caused by extrinsic positioning may be confused with sagittal
synostosis, a more serious deformity that usually requires surgery to correct.
6
What is Craniosynostosis?
Craniosynostosis is the premature closure of one or more cranial sutures. Treatment
of craniosynostosis usually requires surgical intervention. Craniosynostosis restricts
growth at the involved suture and causes excessive growth perpendicular to the
fused suture. Early referral to a specialist is always recommended. There are different
types of craniosynostosis, including: sagittal, coronal, metopic, and lambdoid.
Infants diagnosed with craniosynostosis usually require surgery and should be
referred immediately to a pediatric neurosurgeon or craniofacial specialist for further
evaluation and treatment. Early diagnosis is vital. Endoscopic surgeries are often
recommended before 3 months of age.
SAGITTAL SYNOSTOSIS is the most common type of single suture craniosynostosis
and results in a scaphocephalic head shape.
••
Sagittal suture is usually ridged.
••
Posterior cranial vault slopes inferiorly.
••
Frontal and occipital bones have a pinched/boxy shape.
••
The skull becomes progressively more abnormal and does not improve
with repositioning.
7
LAMBDOID SYNOSTOSIS is the least common type of craniosynostosis and can be
confused with plagiocephaly.
••
Significant occipital asymmetry without anterior ear shift or frontal changes.
••
Mastoid bossing on the side of occipital flattening.
••
Contralateral parietal bossing.
Other types of synostosis include metopic, uni-coronal, bi-coronal and synostoses that
are manifested in syndromal disorders like Apert’s and Crouzon’s.
See page 9 to learn more about differentiating lambdoid synostosis
and plagiocephaly.
8
Deformational Plagiocephaly vs. Lambdoid
Craniosynostosis
Deformational plagiocephaly can be difficult to differentiate from lambdoid
craniosynostosis because both conditions present with asymmetry. The two
deformities are shown below in the vertex view. Refer the infant to a specialist if
the diagnosis is unclear.
DEFORMATIONAL PLAGIOCEPHALY
Midline
Ipsilateral
frontal
bossing
LAMBDOID CRANIOSYNOSTOSIS
NO ipsilateral frontal bossing
Ipsilateral POSTERIOR
ear displacement (usually)
Ipsilateral ANTERIOR
ear displacement
Ipsilateral
mastoid
bossing
Occipital flattening with
contralateral bossing
Midline
Significant occipital
flattening that worsens
over time
9
Patient Evaluation
Examination of the infant skull is essential to differentiate deformational skull shape
abnormalities from deformities secondary to craniosynostosis.
Clinical
Indicators
Normal
Deformational
Skull Shape
Craniosynostosis
Suspected
Fontanelles
and Sutures
Normal size for
age of child,
no depression
or bulging, no
ridging over
sutures.
Normal size for age of child,
no depression, bulging, or
ridges over sutures.
Abnormal size or other atypical appearance of
fontanelle. Suture(s) may be ridged.
Proportion
Average width
of the skull is
76-83% of the
length of the
skull.
Brachycephaly or Brachycephaly
with Asymmetry: Width is
>91% of length.
Coronal Synostosis: Width may be >85% of length.
Occiput and
Parietal
Bones
Occiput and
parietal bones
are symmetrical.
Plagiocephaly or Brachycephaly
with Asymmetry: Unilateral
flattening that may cross
midline. Occipital bossing
on side opposite flattening.
Unilateral Lambdoid Synostosis: Impressive
unilateral occipital flattening, contra-lateral
parietal bossing.
Mastoid
Not prominent.
with Asymmetry: Mastoid is
not prominent.
Unilateral Lambdoid Synostosis: Significant mastoid
(not occipital) prominence on side of occipital
flattening.
Forehead
Normal
appearance and
symmetrical.
with Asymmetry: Forehead
more prominent on side of
occipital flattening.
Unicoronal: Forehead abnormally flat on the
affected side. Tip of nose and chin pointing
away from affected side.
Scaphocephaly: Width is <76%
of the length.
Brachycephaly: Both sides
of forehead abnormally
bulged and prominent.
Scaphocephaly: Narrow,
bossed forehead.
Sagittal Synostosis: Skull is noticeably elongated,
and may be <76% of length.
Bicoronal Synostosis: Abnormally flat and tall
forehead, turicephalic.
Sagittal Synostosis: Narrow head shape. Anterior
frontal bossing (may appear "boxy"), narrow
parietals and occipital bossing.
Metopic Synostosis: Metopic suture is prominent
and forehead is angulated centrally.
10
Patient Evaluation—Continued
Clinical
Indicators
Normal
Deformational
Skull Shape
Craniosynostosis
Suspected
Eyes/Orbits
Eyes symmetrical.
Plagiocephaly or Brachycephaly with
Asymmetry: Eye size may be
asymmetrical.
Unicoronal Synostosis: Eye on side of
flattened frontal bone is positioned
higher and more open than
opposite side (harlequin sign).
Ear Position
Ears are
symmetrical
in height and
placement.
with Asymmetry: Ear on side
of occipital flattening is
displaced more anterior than
contralateral ear.
Unilambdoid Synostosis: Ear on side
of occipital flattening is displaced
vertically and in a posterior direction
toward the closed suture.
Unicoronal Synostosis: Ear is displaced
vertically toward the fused coronal
suture.
Face
Forehead, eyes,
cheeks, mandible
and chin are
symmetrical.
with Asymmetry: Forehead, eyes,
cheeks, mandible and chin may
be asymmetrical.
Brachycephaly and Scaphocephaly:
Facial features are symmetrical.
11
Unicoronal Synostosis: Eyes
asymmetrical, nasal root displaced
toward side of fused coronal suture,
chin displaced away from closed
coronal suture.
Evaluating Neck Strength and Range of
Motion for Torticollis
1. Evaluate active neck strength and range of motion to determine whether torticollis or
a positional neck preference is contributing to the abnormal skull shape.
2. Stimulate the infant to visually track an object to each side. Babies with torticollis may
compensate for limited range by turning the shoulders at the endpoint of their range
or tipping their head back while simultaneously jutting their chin forward.
3. Assess head tilt, skin fold symmetry and occipital hair growth patterns, which may
indicate prolonged head/neck positioning.
4. Hold the infant at arm's length and gently tip to each side. If the baby shows
asymmetric head righting ability, neck weakness or limitation may be present.
5. Refer the infant to a physical or occupational therapist if torticollis or neck asymmetry
is present, particularly if a home developmental program fails to resolve the problem
after 3 months of age.
Pronounced Head Tilt
Asymmetrical Skin Folds
12
Unilateral hair loss
Can Deformational Plagiocephaly
be Prevented?
While not all deformational plagiocephaly cases will correct on their own, there are
some efforts that can help prevent or reduce its effects:
••
Frequent changes in body and head positions (repositioning strategies) incorporated
into a tummy time home program.
••
Prone positioning when the infant is awake and supervised.
••
Limit time in carriers and positioning devices.
••
Prescribe therapy at 3 months or earlier if there is strong positional head/neck
preference, torticollis, and/or significant developmental delay.
ols
Tummy Time To
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a baby to tilt
Dulcey Lima, C.O.,
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For more informat
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contact your pediatric
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Orthomerica Product
Blossom Trail
6333 N. Orange
Orlando, FL 32810
TEL: 877-737-8444
FAX: 877-737-8445
ca.com
www.orthomeri
ds.com
www.starbandki
back of
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When a baby develops
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made worse
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a
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interesting toys
give your baby
and play with
Visit STARbandkids.com/library
to download a FREE copy of
Tummy Time Tools! This guide
offers a variety of repositioning
techniques that families can
incorporate into a daily routine
to increase the time infants
spend off their backs.
13
Assessment of Severity and
Suggested Action
Severity
Normal–Mild
Deformational Plagiocephaly
Brachycephaly
Brachycephaly with Asymmetry
Skull is symmetrical and well
proportioned. Some mild
asymmetry may be present
but it is within normal limits
(WNL.)
Skull is well proportioned. It
may be wider than normal
but is WNL.
Skull may be slightly
asymmetrical and wide but
is WNL.
The skull has unilateral
occipital flattening. The ear
on the ipsilateral side may be
displaced anteriorally.
The skull has central
occipital flattening with
compensatory growth
laterally.
Skull is abnormally wide.
Occipital asymmetry extends
past midline. Ipsilateral ear
may be displaced forward.
Action: Monitor.
Moderate
Action: Refer for STARband if baby is >3 months and <18 months.
oderate–
M
Severe
Significant occipital
flattening, ear on the
ipsilateral side displaced
anteriorally, ipsilateral frontal
bone is bossed, contralateral
frontal bone may appear to
be more flat.
Central occipital flattening
with compensatory growth
laterally creating a very wide
head with bilateral frontal
bossing.
Occipital flattening extends
beyond midline with
contralateral occipital
bossing. Skull is very wide
for its length with significant
ear shift, ipsilateral frontal
bossing and contralateral
frontal flattening.
Severe
Skull shape is very abnormal
with unilateral occipital
flattening and contralateral
occipital bossing. The
ipsilateral ear is displaced
forward, with significant
frontal asymmetry including
forehead, orbits, cheeks and
mandible.
Occiput is extremely flat,
parietal bones are displaced
laterally creating a very
wide head, high and sloped
cranial vault, and significant
frontal bossing.
14
Skull is both asymmetrical
and disproportionate with
significant frontal changes
including ipsilateral frontal
bossing and asymmetry
of the orbits, cheeks and
mandible.
Treatment of Plagiocephaly with a
STARband® Cranial Remolding Orthosis
••
Refer for a STARband if the skull deformity is moderate
to severe. Mild deformities should be documented and
monitored.
••
Ideal cranial orthosis treatment results are achieved
when infants begin treatment before 6 months of age
when the skull is rapidly growing. (Please allow up to 4
weeks from the time of referral to the start of treatment
so proper documentation can be submitted to the
insurance company for coverage).
••
The STARband is best prescribed during the first year of
life, but can be used on infants up to 18 months of age.
••
Multiple studies have demonstrated that cranial
remolding orthoses are more effective than
repositioning in correcting skull deformities.
••
Many infants benefit from concurrent physical therapy
and orthotic intervention, particularly if the infant has
significant neck/torticollis issues.
••
The STARband gently molds the infant's skull into a more
symmetrical and well-proportioned shape.
••
The STARband has 510k clearance from the FDA.
The FDA regulates cranial devices to ensure
safety, quality and effectiveness.
(Continued)
15
Before STARband Treatment
After STARband Treatment
••
The STARband is worn 23 hours per day for an average of 3-4 months.
••
Most infants successfully complete treatment for plagiocephaly with a
single STARband.
••
Treatment success directly correlates with parental compliance.
Contraindications of Cranial
Remolding Orthoses
Infants with head shape asymmetry are not candidates
for cranial remolding orthosis treatment if:
••
The infant is younger than 3 months.
••
The infant is older than 18 months.
••
The infant has untreated craniosynostosis.
••
The infant has hydrocephalus.
16
OVER
200,000
INFANTS
TREATED
The STARband® Cranial Remolding Orthosis and STARscanner™ Laser Data
Acquisition System from Orthomerica have been used by leading physicians,
hospitals and treatment centers throughout the world since 2001.
Key Benefits:
••
Over 200,000 Infants successfully treated with the STARband and
growing exponentially!
••
Largest selection of FDA cleared designs for treatment of deformational
plagiocephaly and craniosynostosis
••
Over 160 STARscanners used in prestigious institutions worldwide
••
Scan infant’s head shape in 2 seconds or less eliminating the need for plaster casting
••
Capture 3-D Data that can be viewed in multiple planes
Visit www.STARbandkids.com to find a location near you.
17
SL00171 Rev. C

Evaluation and Treatment of Deformational

Transcription

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