Analysis of the correlation between deformational plagiocephaly and neurodevelopmental delay

The purpose of this study was to investigate the prevalence of neurodevelopmental delay among deformational plagiocephaly (DP) children, and to confirm relationship between neurodevelopmental delay and severity of DP.This study is retrospective study. Five hundred thirteen children who visited for abnormal head shape through outpatient department were recruited. To identify the children with neurodevelopmental delay among the 513 children with DP, Denver Development Screening Test (DDST) was performed in 38 children who suspected of neurodevelopmental delay. Cranial vault asymmetry (CVA) was measured by using caliper, and cranial vault asymmetry index (CVAI) was calculated. Thirty eight children with DP who conducted DDST were divided into 2 groups according to the degree of CVA; group 1 included 21 children with CVA under 10 mm, and group 2 included 17 children with CVA over 10 mm.There was a significant difference in number of neurodevelopmental delay between group 1 (n = 7) and group 2 (n = 14) (P < .05). Mean grade of DP, CVA, and CVAI (1.76 ± 0.44, 5.90 ± 2.21 mm, 4.20 ± 1.51%) in group 1 was smaller than that in group 2 (3.41 ± 0.8, 12.71 ± 3.22 mm, 8.83 ± 2.18%), respectively (P < .05).Our results found that the frequency of developmental delay was significantly increased in children with CVA more than 10 mm. Doctors who take care of children with DP had better keep developmental delays in mild.

Purpose: to develop and validate algorithms that enable a novice user to quantitatively measure the head shape parameters associated with deformational plagiocephaly, and brachycephaly (DPB) using a smartphone or tablet. Method: We have developed a technology (called SoftSpot^TM) based on advanced imaging algorithms to detect different types and severity of DPB from top-view photos of the head acquired by a novice user at the point-of-care, i.e. in pediatric offices, and at home. Currently, the head shape parameters are measured using either a 3D scanner or a mechanical caliper by a specialist such a pediatric neurosurgeon or an orthotist. In our approach, the head contour is extracted semiautomatically using the intelligent scissors method. We then automatically compute two indices used in the clinical determination of the DPB: the cranial index (CI), and the cranial vault asymmetry index (CVAI). In this paper, we also present methods to quantify, and compensate for the user variability in the acquisition of photos, including camera angle, and distance from the head, by combining the results from different camera positions. We compared the results of our technology with ground truth measurements from 53 infants with DPB, and normal cranial parameters. Accuracy analysis was performed by Bland Altman (BA) method, and the Spearman correlation test. Results: The Spearman correlation coefficients between the new 2D method, and the 3D ground truth were 0.94 (p&lt;0.001), and 0.96 (p&lt;0.001) for CI and CVAI, respectively. Different camera angles, and distances from the head resulted in variation in CI and CVAI in the range of [-2.0, 6.0], and [-4.0, 4.0] units, respectively. The limit of agreement was reduced from [-3.6, 5.3], and [-3.6, 4.2] to [-0.5, 3.0], and [-1.3, 1.6] for CI and CVAI, respectively, by combining results from different camera angles, and positions in our method. The overall accuracy of the proposed technology for DPB detection was 100%. Conclusions: Photographic 2D images can be accurately analyzed to assess DPB at the point-of-care. By compensating for the error from variable camera angles, and distance from the head, our technology eliminates user variability. The algorithms will be packaged in a mobile application to enable the use of the technology at the point-of-care.

As there are very few long-term studies on the effects of head orthosis on deformational plagiocephaly (DP), we investigated the outcomes of patients, including facial symmetry and dental occlusion. Forty-five infants with DP [cranial vault asymmetry index (CVAI) > 3.5 per cent] were divided into two groups: one treated with head orthosis (32 infants) and another without (13 infants). Another group without head asymmetry (CVAI ≤ 3.5 per cent) served as control. Using 3D-stereophotogrammetry, cranial asymmetry was analysed using symmetry-related variables [CVAI, posterior cranial asymmetry index (PCAI), and ear offset]. Data acquisition was performed before (T1) and at the end of treatment (T2), and at the age of 4 years (T3) for the treated group and at T1 and T3 for the remaining groups. Parameters of facial symmetry and dental occlusion were assessed at T3 for infants with DP. Symmetry-related variables (∆T1-T3) improved significantly more in the treated than the control group, whereas these parameters did not differ significantly between the untreated and control group. Comparing the treated and untreated groups between T1 and T3, the reduction in the asymmetry at the treated group was significantly higher for the CVAI and PCAI. In follow-up, the untreated group showed higher incidences of facial asymmetries than the treated group. Seventy-five per cent of all lateral crossbites found in patients with DP were contralateral to the posterior flattening. Due to ethical reasons, the investigation is a non-randomized study. Parameters of facial symmetry were only assed for the treated and untreated groups. Head orthosis therapy in patients with DP leads to significantly better long-term outcomes. Facial asymmetries are more frequent in patients with DP who do not receive this treatment.

ObjectiveTo compare a new ultrasound measurement method with calliper cephalometry in infants with deformational plagiocephaly (DP) and to assess the differences of two methods according to the severity of DP.MethodsFifty-two infants with DP were divided into two groups according to the degree of cranial vault asymmetry (CVA); group 1 included 42 infants with CVA over 10 mm, and group 2 included 10 infants with CVA under 10 mm. Cranial vault asymmetry index (CVAI) and occipital angle ratio (OAR) were measured by using calliper and ultrasound measurements, respectively. The occipital angle was defined as the angle between the lines projected along the lambdoid sutures of the skull.ResultsThe occipital angles of the affected sides were significantly greater than those of unaffected sides in both groups. The CVAI and OAR were significantly greater in group 1 than in group 2 (CVAI, 9.3%±2.3% vs. 4.6%±1.5%; OAR, 1.05±0.4 vs. 1.01±0.0; p<0.05). The OAR was positively correlated with the CVAI in all infants (r=0.789) and in group 1 (r=0.784; p<0.05).ConclusionOur study revealed that OAR using the new ultrasound measurement was positively correlated with the CVAI in infants with DP. Therefore, the occipital angle measurement using ultrasound combined with cephalometry could provide better understanding about the characteristics of the overall cranial bone and lambdoid suture complex in infants with DP.

Association between cranial morphology and dysgnathias in adolescents and adults: A prospective case-control study.

To investigate the effects of helmet therapy on plagiocephaly, according to head circumference, cephalic index (CI), and skull height. Plagiocephaly is a condition in which the skull is congenitally asymmetrical or affected by acquired factors such as compression in the womb or the habit of sleeping on one side. Although there are numerous studies on the effectiveness of helmet therapy for plagiocephaly, research on its effectiveness on skull shape is lacking. We conducted a prospective study on 400 patients who underwent helmet therapy. The infants were enrolled and the therapy was explained to the caregiver when the child had positional plagiocephaly and had a cranial vault asymmetry (CVA) exceeding 10 mm or a CVA index (CVAI) exceeding 3.5%. The CVA and CVAI changes were compared to investigate the effectiveness of helmet therapy according to head circumference, CI, and skull height. A significant treatment effect was observed for CI values between 90 and 103. The treatment effect was found to increase with greater skull height. However, no significant difference was observed in the effectiveness of helmet therapy according to head circumference. According to the findings, the effectiveness of helmet therapy in children with positional plagiocephaly is greater for children with higher skulls and for those with CI values between 90 and 103; it is unrelated to head circumference. Based on these results, we can provide predictions of the effectiveness of helmet therapy to caregivers of children with positional plagiocephaly.

Helmet therapy is widely accepted in the treatment of severe positional plagiocephaly. The improvement of the cranial asymmetry under therapy is evident, but parents are also concerned about the ear shift. Our study investigated the influence of helmet therapy on the position of the ears and analyzed the reliability of clinical observations regarding cranial asymmetry and ear shift. Three-dimensional stereophotogrammetry of 80 infants with severe positional plagiocephaly was performed before and after helmet therapy. The cranial vault asymmetry index (CVAI) and ear shift were measured and statistically compared. The correlation between the change of CVAI and ear shift was investigated. Three surgeons visually evaluated the treatment results on three-dimensional images independently with a standard questionnaire. The results were compared with the three-dimensional measurements. Sixty infants had a relevant initial ear shift. Under therapy, the shift was improved significantly by a mean of 29.8% (P < 0.001). Twenty infants with an initial straight ear line statistically deteriorate under therapy (P < 0.0001). We found no strong linear correlation between the changes of the CVAI and the ear shift. Analysis of the questionnaire revealed a good correlation between the clinical impression and three-dimensional measurements for the head asymmetry, whereas observations regarding changes in the ear shift were not reliable. Helmet treatment significantly improves an initial malposition of the external ear in infants with positional plagiocephaly. A severe ear shift can be associated with a moderate CVAI and vice versa. In contrast to the CVAI, small changes of the ear shift cannot be evaluated reliably by clinical investigation.

-The purpose of this study was to investigate the changes in skull shape on sonography after cranial molding helmet therapy in infants with deformational plagiocephaly. -Twenty-six infants who were treated with cranial molding helmet therapy were recruited. Caliper and sonographic measurements were performed. The lateral length of the affected and unaffected sides of the skull and cranial vault asymmetry index were measured with calipers. The occipital angle, defined as the angle between lines projected along the lambdoid sutures of the skull, was calculated by sonography. The occipital angle difference and occipital angle ratio were also measured. All caliper and sonographic measurements were performed in each infant twice before and twice after treatment. -The study group included 12 male and 14 female infants with a mean age ± SD of 6.2 ± 3.5 months. The mean treatment duration was 6.0 ± 2.5 months. The difference in lateral length before and after helmet therapy was significantly greater on the affected skull than the unaffected skull (16.7 ± 12.7 versus 9.0 ± 13.4 mm; P < .01). The difference in the occipital angle before and after helmet therapy was significantly greater on the affected skull than the unaffected skull (-5.7° ± 7.3° versus 4.2° ± 7.9°; P < .01). The cranial vault asymmetry index and occipital angle ratio were significantly reduced after helmet therapy (cranial vault asymmetry index, 9.3% ± 2.3% versus 3.5% ± 3.0%; occipital angle ratio, 1.07 ± 0.05 versus 1.01 ± 0.01; P < .05). -These results suggest that occipital angle measurements using sonography, combined with cephalometry, could provide a better understanding of the therapeutic effects of cranial molding helmet therapy in infants with deformational plagiocephaly.

Children with end-stage liver disease and liver transplantation (LT) during the first 12 months of life are exposed to many potential neurological insults during the most vulnerable period of brain growth. We describe the developmental outcome in infants transplanted at the University of Alberta, Stollery Children's Hospital. Methods: Infants ≤12 months of age who had a LT between 1990-2004 were registered and followed by the Complex Pediatrics Therapies Project. The children were assessed between 6 to 12 months post-LT with a neurological examination, audiology and administered the Bayley Scales of Infant Development-II (BSID-II). The BSID-II provides a Mental Development Index (MDI) which has a population normative score of 100 ± 15. Developmental delay is defined as a MDI of <70 and borderline delay 84-70. The registry also recorded potential predictive variables including age at LT, socioeconomic status (SES), diagnosis, growth and serum bilirubin and ammonia. Results: During this period, 27 grafts were transplanted into 24 recipients, with a patient survival of 21/24 (87.5%) and a graft survival of 21/27 (77.8%). Follow-up was available on 18/21 (85.7%) survivors. Etiology of the 18 children included biliary atresia n = 14 and other n = 4. The mean MDI was 77.1 ≤ 16.9 (range 109-49) with only 4 (22%) children having a MDI >85 (normal development), 9 (50%) had a MDI 84-70 (borderline delay) and 5 (28%) had a MDI <70 (developmental delay). Compared to the expected general population, prevalence of borderline delay was 3 times and developmental delay 14 times the expected rate. There was no correlation between MDI and the age at LT, SES, diagnosis, growth and pretransplant serum bilirubin and ammonia. Conclusion: End-stage liver disease and LT in infancy results in over 75% of children with borderline or developmental delay. All infants should have thorough developmental assessments to enable them to receive appropriate supports and learning environments to maximize their potential.

ObjectiveTo compare effectiveness on correcting cranial and ear asymmetry between helmet therapy and counter positioning for deformational plagiocephaly (DP).MethodsRetrospective data of children diagnosed with DP who visited our clinic from November 2010 to October 2012 were reviewed. Subjects ≤10 months of age who showed ≥10 mm of diagonal difference were included for analysis. For DP treatment, information on both helmet therapy and counter positioning was given and either of the two was chosen by each family. Head circumference, cranial asymmetry measurements including diagonal difference, cranial vault asymmetry index, radial symmetry index, and ear shift were obtained by 3-dimensional head-surface laser scan at the time of initiation and termination of therapy.ResultsTwenty-seven subjects were included: 21 had helmet therapy and 6 underwent counter positioning. There was no significant difference of baseline characteristics, head circumferences and cranial asymmetry measurements at the initiation of therapy. The mean duration of therapy was 4.30±1.27 months in the helmet therapy group and 4.08±0.95 months in the counter positioning group (p=0.770). While cranial asymmetry measurements improved in both groups, significantly more improvement was observed with helmet therapy. There was no significant difference of the head circumference growth between the two groups at the end of therapy.ConclusionHelmet therapy resulted in more favorable outcomes in correcting cranial and ear asymmetry than counter positioning on moderate to severe DP without compromising head growth.

INTRODUCTION: Positional plagiocephaly is a common condition with controversy regarding optimal treatment modality. Treatment options include repositioning exercises, watchful waiting, cranial molding orthotics, and in rare cases surgery. Conservative therapy with repositioning therapy (RT) +/- physical therapy (PT) is known to be successful in a large portion of these patients1. Recently an article in British Journal of Medicine2 featured in Wall Street Journal stated watchful waiting is as effective as helmet therapy. Our aim was to determine the effectiveness of helmet therapy for positional skull deformation in a single providers practice. MATERIALS AND METHODS: 4248 patients were seen and evaluated for positional plagiocephaly were assigned either conservative treatment (RT +/- PT, n=3186) or Helmet therapy (n=1062). Patients assigned to helmet therapy were treated by a single orthotist using the single orthotic manufacturer. Patients were followed until complete correction (Diagonal Difference<6, EPSR>90%, Cephalic Index 0.75–0.91, Cranial Vault Asymmetry Index<6). RESULTS: Age at initial evaluation ranged from 3–12 months. Complete correction was achieved in 75% of patients with conservative treatment (n=3186). 25% transitioned to helmet therapy (n=1062). Average helmet treatment duration was 5 months with 95% having complete correction of deformity with a single helmet. 5% of patients required a second helmet for additional correction (n=49) with 0.01% requiring a third helmet to achieve complete correction (n=8). Risk factors for failure of conservative therapy included advanced age, torticollis, and severity of cephalic ratio and diagonal difference. CONCLUSION: Conservative and helmet therapy can effectively treat positional plagiocephaly. In children who could benefit from helmet therapy, a single helmet fabricated by a skilled orthotist and followed by a craniofacial surgeon can correct deformational skull deformities in nearly all infants. These results are consistent with previous studies, but conflicts the BJM article. This is important, as this article can be the source of insurance denials for infants who could clearly benefit from cranial molding orthotics. Further large randomized trials would help answer this challenging question.

Deformational Plagiocephaly (DP) is a multi-planar deformity of the cranium occurring either pre-or postnatally in infants. In the last decade, the incidence of DP has increased substantially due to a number of factors, including supine sleeping positioning to reduce Sudden Infant Death Syndrome and the use of child carriers that increase supine positioning. Clinical questions persist about which children should be treated for DP and how to intervene, questions that are difficult to answer without accurate documentation of three-dimensional (3-D) head shape. This study explored a method for quantifying head shape and used that method to evaluate the success of orthotic treatment. Two hundred twenty-four infants who were diagnosed with DP received either a cranial remolding orthosis or a repositioning program with no orthotic intervention. Data from 25 head shape variables were collected using a noninvasive laser shape digitizer. Only variables attributable to growth showed significant differences in the control population, while the treatment population showed significant differences in pre-and post-treatment values for all variables. The study identified four variables as particularly important in assessing the head shape of infants with plagiocephaly: the cranial vault asymmetry index, radial symmetry index, posterior symmetry ratio, and overall symmetry ratio. Ninety-six percent or more of subjects in the treatment group showed improvement in each variable. These data document the utility of a 3-D scanning device and the effectiveness of treatment with a cranial remolding orthosis.

The incidence of positional skull deformities in infants has increased following campaigns promoting supine sleeping to reduce SIDS. Although various measurement methods exist to quantify cranial asymmetries, discrepancies between direct anthropometry, 3-dimensional photogrammetry, and plagiocephalometry may lead to differing severity classifications and treatment indications. Comparison of the available measurement protocols is crucial to harmonize assessment of these deformities. To prospectively compare 3 measurement techniques-caliper-based (spreading caliper and measuring tape), 3D photogrammetry, and plagiocephalometry-for evaluating cranial deformity in early infancy, to assess their reproducibility and their individual impact on clinical decision-making. In a prospective study, 51 infants aged 3 to 12 months were examined during an outpatient "helmet consultation." Each infant underwent measurements using: (1) standardized direct anthropometry (caliper and tape measurement), (2) 3D photogrammetry with a multicamera system and subsequent semiautomated analysis via the Software Cranioform Analytics 4.0, and (3) plagiocephalometry (PCM) using a thermoplastic strip technique and indirect measurement. Key indices-the cephalic index (CI) and cranial vault asymmetry index (CVAI) (or ODDI for plagiocephalometry)-were calculated. For PCM, a variance component analysis was performed to assess inter- and intraobserver variability. Bland-Altman analyses were used to compare CI and CVAI/ODDI values among the methods, treatment cutoffs were evaluated. Since reproducibility for caliper measurements was already tested for inter- and intraobserver variability, this method was defined "gold standard" at our center. The treatment threshold for this analytical method was a CVA ≥ 1.0cm. 3D photogrammetry-with a treatment cutoff at values above the 97th percentile of normative values-demonstrated excellent reproducibility with minimal bias (systematic error in CI of -0.77), whereas plagiocephalometry-with predefined cutoffs-exhibited a slightly higher bias in CI (-1.35). Cranial vault asymmetry index values varied-also due to differing calculation methods described in the available literature. Variance component analysis of plagiocephalometry indicated interobserver and intraobserver contributions below 3%. Discrepancies in measurement planes, angles, and index calculation furthermore led to differences in treatment indications: caliper screening identified more infants with an indication for orthotic treatment for deformational plagiocephaly than did the other 2 methods. While all 3 techniques provide valuable information, caliper measurement remains a rapid, cost-effective, and fast screening tool. Subsequent evaluation with 3D photogrammetry is recommended for treatment planning. Plagiocephalometry-although provided with high intra- and interrater reliablity-offers no significant advantages in daily practice. Standardization of measurement landmarks and definition of index calculation is needed to internationally standardize and harmonize clinical decision-making.

Introduction: Infants treated for positional cranial asymmetry involving plagiocephaly, brachycephaly, and scaphocephaly are often treated with cranial reshaping orthotic helmets to encourage symmetrical cranial growth. The Michigan Cranial Reshaping Orthosis is a bivalve helmet that accommodates overall cranial growth during the therapy period while still directing cranial growth toward the desired areas. This design differs from standard one-piece helmets that allow limited volume for overall cranial growth. This study examines the efficacy and success rate of this low-profile design. Materials and Methods: Visual inspection and manual measurements taken throughout the helmet therapy period, using a flexible tape measure and an AP-ML gauge, indicate significant cranial asymmetry correction. However, measurement inconsistencies due to soft tissue compression and clinician technique may limit the accuracy of outcome measures. Seventy subjects treated for plagiocephaly and/or brachycephaly with the Michigan Cranial Reshaping Orthosis were identified in this retrospective study. Data were compiled from Omega Tracer (Ohio Willow Wood Company, Mount Sterling, OH, USA) computer-aided design clinical database of three-dimensional cranial scans taken before and after helmet therapy. Cranial helmet therapy treatment timeline was verified through the electronic medical record database. Cranial landmarks were defined on each three-dimensional image. Measurements between defined points were compared on the initial assessment scanned image and the final discharge scanned image for each patient. Results: Comparison of initial and final three-dimensional scans showed improved symmetry in the relevant measures of cranial vault asymmetry index (CVAI) and cephalic ratio (CR) in 84.3% of subjects. Children in the plagiocephaly-only group showed 28.8% improvement in CVAI. Although sample size was low, children in the brachycephaly-only group showed 4.66% improvement in CR. Children in the combined plagiocephaly/brachycephaly group showed 41.4% improvement in CVAI and 2.60% improvement in CR. Overall, a 33.5% in CVAI and 2.10% improvement in CR were seen. These results are comparable to other studies of remolding helmet efficacy. Conclusions: The data in the present study, therefore, support the use of the Michigan Cranial Reshaping Orthosis as a viable option in the treatment of plagiocephaly and/or brachycephaly when the primary method of treatment is utilization of a cranial remolding helmet.

Prevalence of head deformities in preterm infants at term equivalent age