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Williams E1,2, Galea M3,4
1The University of Melbourne, Melbourne, Australia, 2Royal Children's Hospital, Melbourne, Australia, 3The University of Melbourne, Department of Medicine, Melbourne, Australia, 4Royal Melbourne Hospital, Australian Rehabilitation Research Centre, Melbourne, Australia
Background: Since 1992 the “Back to Sleep” campaign to sleep infants in supine has reduced Sudden Infant Deaths (SIDS) but referrals to specialist clinics for deformational or positional plagiocephaly have risen. Occipital plagiocephaly is as high as 46.6% in babies aged 7-12 weeks. The rationale for current prevention advice, prone positioning or tummy time while awake, is that strengthening the neck promotes the development of head control. The question is whether tummy time is the best advice, as the definition of head control is unclear. Because supine sleeping (not in question) and tummy time are established child-rearing practice, there are challenges in translating evidence-based prevention strategies at a population level.
Purpose: The purpose of the research was to investigate physiotherapeutic, evidence-based and child-centred strategies for prevention of plagiocephaly, revisiting the definition and development of infant head control.
Methods: Our mixed methods approach included an audit of specialist plagiocephaly clinics and a survey of community health professionals. Observational video studies in three cohorts used the “pull to sit” tested by a physiotherapist. The three cohorts were: infants attending a specialist plagiocephaly clinic; a normal group aged 4 months (cross sectional); and a longitudinal study of infants 1-6 months. Information was synthesised into a fact sheet for parents and health professionals regarding head control development and this was evaluated by an expert focus group.
Results: A survey of Maternal Child Health Nurses (MCHN) (n=183) and Paediatric Physiotherapists (n= 16) (PP) showed that all saw infants with plagiocephaly, MCHN at 2-3 months and PP at4-6 months. The MCHN reported gaps in prevention advice. Almost 4,000 infants attended a plagiocephaly clinic over 3 years and had an 8-week wait (age 7±2.6 months; 63% male; 71% mild; 8% referred for helmet therapy). A cohort of infants in the plagiocephaly clinic (n=25; age 7±1.8 months) showed poor chin tuck (70%) and early head lag (63%). The cross-sectional study of normal 4-month-old infants (n=53/102 videos) showed that 53% of infants had no chin tuck, and 49% had early head lag. The longitudinal study (n=34/81 videos) was age stratified. At 6-9 weeks infants showed no head control. At 10 weeks 25% achieved head control; by 12 weeks 65% and by 15 weeks 100% had achieved head control on the “pull-to-sit”. Consequently, a new fact sheet, adding “face time” as well as tummy time for head control, was endorsed by an expert focus group and due to demand from MCHN and, with media interest, has resulted in global distribution.
Conclusion(s): A focus on tummy time does not address forward head control, which is atypical in infants with plagiocephaly and some normal infants, so more specific advice for parents and health professionals was indicated. Encouraging earlier chin tuck and supine head control between 1-4 months could potentially assist in plagiocephaly prevention. The fact sheet is now being used by Maternal Child Health Nurses and Paediatric Physiotherapists. Future research to monitor referrals to plagiocephaly clinics is recommended.
Implications: Implementing evidence-based, child-centred advice for infant development by paediatric physiotherapists provides potential for plagiocephaly prevention.
Keywords: Plagiocephaly, Infant development, Head control
Funding acknowledgements: Elizabeth Williams received funding from an NHMRC Australian Postgraduate Award Scholarship for her PhD studies.
Purpose: The purpose of the research was to investigate physiotherapeutic, evidence-based and child-centred strategies for prevention of plagiocephaly, revisiting the definition and development of infant head control.
Methods: Our mixed methods approach included an audit of specialist plagiocephaly clinics and a survey of community health professionals. Observational video studies in three cohorts used the “pull to sit” tested by a physiotherapist. The three cohorts were: infants attending a specialist plagiocephaly clinic; a normal group aged 4 months (cross sectional); and a longitudinal study of infants 1-6 months. Information was synthesised into a fact sheet for parents and health professionals regarding head control development and this was evaluated by an expert focus group.
Results: A survey of Maternal Child Health Nurses (MCHN) (n=183) and Paediatric Physiotherapists (n= 16) (PP) showed that all saw infants with plagiocephaly, MCHN at 2-3 months and PP at4-6 months. The MCHN reported gaps in prevention advice. Almost 4,000 infants attended a plagiocephaly clinic over 3 years and had an 8-week wait (age 7±2.6 months; 63% male; 71% mild; 8% referred for helmet therapy). A cohort of infants in the plagiocephaly clinic (n=25; age 7±1.8 months) showed poor chin tuck (70%) and early head lag (63%). The cross-sectional study of normal 4-month-old infants (n=53/102 videos) showed that 53% of infants had no chin tuck, and 49% had early head lag. The longitudinal study (n=34/81 videos) was age stratified. At 6-9 weeks infants showed no head control. At 10 weeks 25% achieved head control; by 12 weeks 65% and by 15 weeks 100% had achieved head control on the “pull-to-sit”. Consequently, a new fact sheet, adding “face time” as well as tummy time for head control, was endorsed by an expert focus group and due to demand from MCHN and, with media interest, has resulted in global distribution.
Conclusion(s): A focus on tummy time does not address forward head control, which is atypical in infants with plagiocephaly and some normal infants, so more specific advice for parents and health professionals was indicated. Encouraging earlier chin tuck and supine head control between 1-4 months could potentially assist in plagiocephaly prevention. The fact sheet is now being used by Maternal Child Health Nurses and Paediatric Physiotherapists. Future research to monitor referrals to plagiocephaly clinics is recommended.
Implications: Implementing evidence-based, child-centred advice for infant development by paediatric physiotherapists provides potential for plagiocephaly prevention.
Keywords: Plagiocephaly, Infant development, Head control
Funding acknowledgements: Elizabeth Williams received funding from an NHMRC Australian Postgraduate Award Scholarship for her PhD studies.
Topic: Paediatrics; Primary health care
Ethics approval required: Yes
Institution: University of Melbourne; Royal Children''s Hospital; Vic Dept of Education
Ethics committee: Human Research Ethics Committees; Strategy & Review Group
Ethics number: 1442919; 154117; 35270; 36172; 2014_002570; 2015_02920
All authors, affiliations and abstracts have been published as submitted.
