PURLs
Suctioning neonates at birth: Time to change our approach
There’s a better way to clear secretions from a neonate’s mouth and nose, and it’s less likely to cause adverse effects.
PRACTICE CHANGER
Do not recommend helmet therapy for positional skull deformity in infants and children. Wearing a helmet causes adverse effects but does not alter the natural course of head growth.1
Strength of recommendation
B: Based on a single-blind, randomized controlled trial (RCT).
van Wijk RM, van Vlimmeren LA, Groothuis-Oudshoorn CG, et al. Helmet therapy in infants with positional skull deformation: randomised controlled trial. BMJ. 2014;348:g2741.
Illustrative case
The parents of a 6-month-old girl with moderate plagiocephaly bring their daughter in for a well child visit. Previously, you had recommended that the parents increase “tummy time” when the baby is awake, change her position in bed, and monitor the progression of the condition. They do not feel these interventions have made a difference in the shape of their daughter’s skull, and ask about using a helmet to help correct the deformity. How would you counsel them?
Positional skull deformity (PSD) is a common problem of infancy. Approximately 45% of infants ages 7 to 12 weeks are estimated to have PSD, although three-quarters of them have mild cases.2 The incidence of PSD began to increase in 1992 after the American Academy of Pediatrics (AAP) introduced its “Back to Sleep” campaign, which encouraged parents to place their infants on their back at bedtime to reduce sudden infant death syndrome.3
There are 2 common forms of PSD: plagiocephaly, and brachycephaly.1 Plagiocephaly is unilateral occipital flattening, which may be accompanied by ipsilateral forehead prominence and asymmetrical ears. Brachycephaly is symmetric flattening of the back of the head, which can lead to prominence of the temporal areas, making the head appear wide. Children with severe plagiocephaly have a misshapen, asymmetric skull, while children with brachycephaly have a flattened skull. The cranial sutures remain open in both kinds of PSD.
Evaluating infants for PSD is part of the routine physical exam, and when the condition is noted, the exam should also differentiate PSD from other causes of skull deformity, such as craniosynostosis. Infants and preschool-aged children with PSD may score lower on developmental testing than children without skull deformity.4 However, these differences are small and inconsistent (2-3 points on a 100-point scale).4 Skull deformity persists into adolescence in only 1% to 2% of patients.5
Neither the AAP nor the American Academy of Family Physicians has a guideline or consensus statement on PSD. Helmets are intended to correct PSD by fitting closely to an infant’s head but allowing room for the skill to grow at the flattened area.1 A 2011 clinical report by Laughlin et al6 recommended against using helmets for infants with mild to moderate deformities, but stated that there was little evidence of harm. Earlier studies have suggested that physical therapy might be effective for plagiocephaly caught early (7 and 8 weeks of age).7,8 Biggs9 suggested considering helmet therapy for infants whose cranial sutures remain open and who do not respond to 4 to 8 weeks of physical therapy for PSD. van Wijk et al1 conducted an RCT to explore the risks and benefits of helmet therapy for children with PSD.
STUDY SUMMARY: Helmets for infants: No help and some harm
This single-blind RCT of 84 infants ages 5 or 6 months with moderate or severe PSD compared helmet therapy (n=42) to no intervention (allowing natural growth, n=42). Infants were excluded if they had very severe PSD or skull deformity from another cause, such as torticollis or craniosynostosis.
Infants in the helmet therapy group received a custom-made helmet that they wore 23 hours a day until they were a year old, with regular evaluation by an orthotist and modification of the helmet as necessary to allow skull growth. The control group had usual care and no helmet.
The primary outcome was improvement in skull shape at age 24 months as measured by the oblique diameter difference index (ODDI), a unitless measurement of plagiocephaly calculated by taking the ratio of measures of 2 dimensions of cranial diameter, and the cranioproportional index (CPI), a similar measurement of brachycephaly. Infants were considered fully recovered if they achieved an ODDI score of <104% and a CPI score of <90%. These scores indicate a normal head shape; higher scores indicate worse PSD.
At the end of the study, the reduction in ODDI and CPI scores was almost the same in both the helmet therapy and the control groups. Ten children in the helmet group (26%) and 9 in the control group (23%) experienced complete resolution of their PSD (P=.74).