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Difference in Outcome for Patients with Positional Plagiocephaly Treated with Orthotic Helmeting Versus Conservative Measures
Craig Rowin, MD, Zachary M. Hurwitz, MD, Jillian Smith, MD, Andres G. Sarraga, MD, Janice F. Lalikos, MD.
University of Massachusetts, Worcester, MA, USA.

BACKGROUND: In 1992 a definitive demonstration of direct correlation between prone sleeping and the incidence of sudden infant death syndrome was established. The subsequent successful “Back to Sleep” campaign, while decreasing incidence of SIDS, was associated with a dramatic rise in rates of positional plagiocephaly. Prior to 1992 the incidence of plagiocephaly was estimated at 1 in 300 infants. Current estimates are as high as 16% to 48% of healthy infants under 1 year old. Under treatment of these infants can result in residual deformity with neurological and cosmetic consequences while unnecessary helmeting brings considerable cost and inconvenience. Although conservative and orthotic therapy is accepted for subjectively mild and severe plagiocephaly patients respectively, there are no clear guidelines for patient with a moderate presentation. Using data from the University of Massachusetts plagiocephaly clinic we measure subjective and objective measurements in moderate patients treated conservatively versus orthotic helmeting in order to quantify a difference in outcome, if present.
METHODS: A retrospective chart review of clinic patients with a non-synostotic diagnosis of mild-moderate, moderate, and moderate-severe plagiocephaly at initial visit. These patients were divided into conservative(n=30) and helmeting(n=49) treatment groups and observed at 6 month and, when available, 12 month intervals. All Subjective classifications determined by a single craniofacial surgeon, and were assigned a sequential numerical value in order to quantify change. Objective measurements consist of difference in left/right frontal to parietal-occipital, frontal to nuchal ridge, and lateral canthus to tragus distances in cm. Changes for the two groups were analyzed for significance with the Wilcoxon two-sided test.
RESULTS: A significant difference between the helmet and conservative groups was seen at 6 months for change in frontal to parietal-occipital discrepancy (0.45 v 0.18, p=0.018) as well as for final subjective change (2.0 v 1.5, p=0.02). Significance of the difference in frontal to parietal-occipital change at 12 months disappears due to both a smaller difference (0.56 v 0.46) and smaller n.
CONCLUSIONS: When considering all moderate categories of plagiocephaly, larger gains are made at 6 months by the helmeted group in a single objective measurement and in subjective improvement. Given known difficulties with precise gathering of objective data and the fact that measurements often do not correlate well with subjective severity, subjective improvement is likely the most valuable measure of outcome. This study will continue to increase in n and power and it will be interesting to see if further significance appears in objective measures or if it persists for subjective improvement at 12 months. 3D surface mapping as a superior method of objective measure is possible and would be a useful area of further investigation.


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