In 1992 the American Academy of Ped...

In 1992 the American Academy of Pediatrics (AAP) initiated the "Back to Sleep" campaign recommending that infants be placed to nap in the supine position to shorten the incidence of sudden infant death syndrome (SIDS). (1) Although the rate of SIDS decreased from 1992 to 2000 (2) the practice of placing an infant in succession the back during sleep can end in flattening of the occipital area of the cranium The incidence of positional head deformity is estimated to have risen fivefold since 1992 and the condition now may be met with in one of every 60 live births. (3) Family physicians should gaze for positional head deformity because early intervention may contract adverse outcomes.

Illustrated Case

An otherwise healthy 10-week-old stripling had facial asymmetry with his organ of visions not in alignment. He was delivered vaginally after a normal pregnancy, and there were no significant antenatal, delivery, or postnatal complications. At four month of age his vigilances appeared unequal in position, the right occiput was markedly flattened, and the right forehead protuberant (Figure 1) Consultation with a craniofacial surgeon produc a diagnosis of positional head deformity (posterior plagiocephaly), and the child was referr to a pediatric physical therapist.

Definitions and Etiology

Plagiocephaly is derived from the after the greek words meaning "oblique head." The condition can be derived from either premature closure of the lambdoidal line of junction (synostotic plagiocephaly) or positional head deformity (nonsynostotic plagiocephaly). Synostotic plagiocephaly arises in approximately one of each 100,000 infants. (4) Positional head deformity is not as rare; before 1996 the incidence was united of every 300 healthy infants. (5) Positional head deformity is caused according to external pressures on the rapidly developing brain-pan from prolonged exposure to the same position. Risk factors associated with positional head deformity are premature birth, hypotonic muscle disorders, congenital torticollis, and intrauterine constraint (such as in multiple gestation or oligohydramnios). (6)

In 1993 the American Society of Craniofacial Surgeon noted an increase in the incidence of posterior cranial deformities in infants who had no predisposing risk factors. (7) These reports were similar to increases in the incidence reported in other countries. (8) The relationship of this increased incidence to the "Back to Sleep" campaign was propos in 1996 and was supported through evidence of a rapid increase in positional head deformity without any significant change in the rate of synostotic plagiocephaly. (8) A thought (9) comparing the periods 1990 to 1992 with 1992 to 1994 demonstrated a fivefold increase in the incidence of positional head deformity and lay the foundation of that all affected infants were supine sleepers

Diagnosis

The physician should first determine whether the infant has synostotic plagiocephaly or positional head deformity, because the couple conditions have very different clinical implications and treatments (Table 1) In in the greatest degree cases of synostotic plagiocephaly, a palpable ridge will form. The position of the ear also can be used to distinguish between these sum of two units causes: if the ear in succession the flattened side is located more posterior than the other ear, this is suggestive of synostotic plagiocephaly, and if the ear forward the flattened side is located more anterior than the other ear, this is suggestive of positional head deformity. Positional head deformity brings more facial asymmetry than synostotic plagiocephaly, because of the forehead protruding onward the side of the flattening (Figure 2)

Physicians many times measure the head circumference nevertheless fail to evaluate the shape of the head. most numerous infants will have a "bald spot" caused by means of sleeping in a supine position. If the bald blot is predominantly unilateral, the physician should palpate the occiput for significant flattening. Viewing the infant from an aerial view may present to view the typical "parallelogram" shape of positional head deformity (Figure 3) (6) The physician should confirm that the infant's ears are in a similar position onward each side of the head and that the line of the sights is horizontal. If either of these facial features is different, a positional head deformity may be present

Treatment

Early recognition of positional head deformity is crucial given the rapidly growing cranium of an infant. As the child bring outs a preference for positioning, the ipsilateral sternocleidomastoid muscle shortens resulting in torticollis. This is in contrast to the infant with congenital torticollis in which the rotate and tilt of the head initiates the side predilection and the occiput flattens correspondingly. Sleeping in the supine position and feedings always propounded from the same side correlate with a positional head deformity. (10) Physical therapy aims to educate the child's parents and caregivers about positional head deformity and to teach them exercises that will correct the shortening of the sternocleidomastoid muscle (Table 2) Pediatric physical therapists can teach caregivers by what means to carry the child to lengthen the sternocleidomastoid muscle, for what reason to encourage prone playing, and by what means to alter eating positions to diminish the side preference