Deformational plagiocephaly delays motor skill development in 6-month-old infants

Article Outline

• Question
• Design
• Setting
• Participants
• Intervention
• Outcomes
• Main Results
• Conclusions
• Commentary
• Reference
• Copyright

Speltz ML, Collett BR, Stott-Miller M, Starr JR, Heike C, Wolfram-Aduan AM, et al. Case-control study of neurodevelopment in deformational plagiocephaly. Pediatrics 2010;125:e537-42.

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Question 

Among infants with deformational plagiocephaly (DP), is there a difference in the neurodevelopment at an average age of 6 months?

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Design 

Case-control study.

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Setting 

Seattle Children's Hospital, Seattle, Washington.

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Participants 

Two hundred thirty-five infants (diagnosed between the ages of 4 and 11 months) who were referred to the craniofacial center for evaluation of DP. Control subjects were 237 otherwise healthy infants recruited from the community.

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Intervention 

The Bayley Scales of Infant Development III (BSID-III) were administered. Three-dimensional head photographs were randomized and rated for severity of deformation by two craniofacial dysmorphologists who were blinded to case status.

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Outcomes 

Severity of cranial deformation and scores on the Bayley Scales.

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Main Results 

Of the participants, two case subjects with no photographic evidence of DP and 70 control subjects who were judged to have some degree of DP were excluded. With control for age, sex, and socioeconomic status, case subjects performed worse than control subjects on all BSID-III scales and subscales. Case subjects' average scores on the motor composite scale were ∼10 points lower than control subjects' average scores (P < .001). Differences for the cognitive and language composite scales were ∼5 points, on average (P < .001 for both scales). In subscale analyses, case subjects' gross motor deficits were greater than their fine motor deficits. Among case subjects, there was no association between BSID-III performance and the presence of torticollis or infant age at diagnosis.

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Conclusions 

DP seems to be associated with early neurodevelopmental disadvantage, which is most evident in motor functions. These data do not necessarily imply that DP causes neurodevelopmental delay; they indicate only that DP is a marker of elevated risk for delays. Pediatricians should monitor closely the development of infants with this condition.

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Commentary 

The prevalence of posterior DP rose dramatically after the introduction of the “Back to Sleep” program in the early 1990s. This report by Speltz et al illuminates a murky area that has been riddled by poorly designed studies and misinformation.¹ In this well-designed case-control study, the authors compared development skills of a group of 6-month-old infants from a DP clinic with a well-matched control group of normal infants who were volunteered at birth by their parents for childhood outcome studies. Both the DP and the control groups had a higher than expected socioeconomic status; because this study was conducted during an economically challenging period, one could argue both groups were not fully representative of the general pediatric population. When cranial shape was compared with neurodevelopmental performance, infants with DP from the craniofacial clinic scored lower on all scales than control infants with a normal cranial shape. The discrepancy was greatest for motor scores. Interestingly, almost one third (70 infants) of the control group had previously undiagnosed DP, which attests to the high prevalence of this condition. Further, those 70 in the original control group who were subsequently identified with DP from photographs also had lower scores than controls with a normal cranial shape. Whether the early developmental delay persists in children who had DP remains unanswered at this point. Because DP has been exceedingly common for almost two decades, it is likely that health care providers and educators would have recognized a persistent decline in neurodevelopment in this population, if it truly existed. We eagerly await the follow-up data as these study infants become toddlers. In the meantime, this study reinforces the need for neonates and infants to receive supervised prone time while awake to enhance their neurodevelopment as well as their cranial shape. Advising parents of neonates to perform 30 minutes of awake supervised “tummy time” each day to optimize the cranial shape may also have the added benefits of optimizing infant motor skills, and establishing early the daily habit of parental involvement in childhood development.

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Reference 

1. Robinson S, Proctor M. Diagnosis and management of deformational plagiocephaly. J Neurosurg Pediatr. 2009;3:284–295
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