Leo A. van Vlimmeren

Effect of pediatric physical therapy on deformational plagiocephaly in children with positional preference: a randomized controlled trial

OBJECTIVE To study the effect of pediatric physical therapy on positional preference and deformational plagiocephaly. DESIGN Randomized controlled trial. SETTING Bernhoven Hospital, Veghel, the Netherlands. PARTICIPANTS Of 380 infants referred to the examiners at age 7 weeks, 68 (17.9%) met criteria for positional preference, and 65 (17.1%) were enrolled and followed up at ages 6 and 12 months. INTERVENTION Infants with positional preference were randomly assigned to receive either physical therapy (n = 33) or usual care (n = 32). MAIN OUTCOME MEASURES The primary outcome was severe deformational plagiocephaly assessed by plagiocephalometry. The secondary outcomes were positional preference, motor development, and cervical passive range of motion. RESULTS Both groups were comparable at baseline. In the intervention group, the risk for severe deformational plagiocephaly was reduced by 46% at age 6 months (relative risk, 0.54; 95% confidence interval, 0.30-0.98) and 57% at age 12 months (0.43; 0.22-0.85). The numbers of infants with positional preference needed to treat were 3.85 and 3.13 at ages 6 and 12 months, respectively. No infant demonstrated positional preference at follow-up. Motor development was not significantly different between the intervention and usual care groups. Cervical passive range of motion was within the normal range at baseline and at follow-up. When infants were aged 6 months, parents in the intervention group demonstrated significantly more symmetry and less left orientation in nursing, positioning, and handling. CONCLUSION A 4-month standardized pediatric physical therapy program to treat positional preference significantly reduced the prevalence of severe deformational plagiocephaly compared with usual care. CLINICAL TRIAL REGISTRATION isrctn.org Identifier: ISRCTN84132771.

Helmet therapy in infants with positional skull deformation: randomised controlled trial

Objective To determine the effectiveness of helmet therapy for positional skull deformation compared with the natural course of the condition in infants aged 5-6 months. Design Pragmatic, single blinded, randomised controlled trial (HEADS, HElmet therapy Assessment in Deformed Skulls) nested in a prospective cohort study. Setting 29 paediatric physiotherapy practices; helmet therapy was administered at four specialised centres. Participants 84 infants aged 5 to 6 months with moderate to severe skull deformation, who were born after 36 weeks of gestation and had no muscular torticollis, craniosynostosis, or dysmorphic features. Participants were randomly assigned to helmet therapy (n=42) or to natural course of the condition (n=42) according to a randomisation plan with blocks of eight. Interventions Six months of helmet therapy compared with the natural course of skull deformation. In both trial arms parents were asked to avoid any (additional) treatment for the skull deformation. Main outcome measures The primary outcome was change in skull shape from baseline to 24 months of age assessed using plagiocephalometry (anthropometric measurement instrument). Change scores for plagiocephaly (oblique diameter difference index) and brachycephaly (cranioproportional index) were each included in an analysis of covariance, using baseline values as the covariate. Secondary outcomes were ear deviation, facial asymmetry, occipital lift, and motor development in the infant, quality of life (infant and parent measures), and parental satisfaction and anxiety. Baseline measurements were performed in infants aged between 5 and 6 months, with follow-up measurements at 8, 12, and 24 months. Primary outcome assessment at 24 months was blinded. Results The change score for both plagiocephaly and brachycephaly was equal between the helmet therapy and natural course groups, with a mean difference of −0.2 (95% confidence interval −1.6 to 1.2, P=0.80) and 0.2 (−1.7 to 2.2, P=0.81), respectively. Full recovery was achieved in 10 of 39 (26%) participants in the helmet therapy group and 9 of 40 (23%) participants in the natural course group (odds ratio 1.2, 95% confidence interval 0.4 to 3.3, P=0.74). All parents reported one or more side effects. Conclusions Based on the equal effectiveness of helmet therapy and skull deformation following its natural course, high prevalence of side effects, and high costs associated with helmet therapy, we discourage the use of a helmet as a standard treatment for healthy infants with moderate to severe skull deformation. Trial registration Current Controlled Trials ISRCTN18473161.

Diagnostic strategies for the evaluation of asymmetry in infancy - a review

Asymmetry in infancy is a diagnosis with a large spectrum of features, expressing an abnormal shape of parts of the body or unequal postures and movements. Symptoms may be structural and/or functional, with localised or generalised expression. Within the last decade, many professionals have focused on the adverse consequences on motor performance of infants, associated with the recommendations on the prevention of sudden infant death. The purpose of the present study was to highlight different aspects of asymmetry in infancy based on best available evidence in the current literature and to present a flow chart illustrating different diagnostic pathways of asymmetry in infancy. Conclusion:we conclude that asymmetry in infancy is a diagnosis with a large spectrum of features and a multifactorial aetiology without consensus in definition, nomenclature and classification. Systematic diagnostic management of asymmetry in infancy is indicated. The presented diagnostic flow chart might serve as a basis.

Motor problems in Prader-Willi syndrome: a systematic review on body composition and neuromuscular functioning.

Motor problems in Prader-Willi syndrome (PWS) are presumably related to abnormal body composition and certain neuromuscular abnormalities. The authors reviewed the literature to evaluate the extent to which body composition is affected and gathered all findings on neuromuscular functioning in PWS. A systematic review was conducted in four databases (1956-2010). The methodological quality of each included article was evaluated. Thirty-eight papers were included: body composition (9 studies), neuromuscular functioning (7) and growth hormone (GH) effect studies (23). Increased fat mass and decreased lean body mass are characteristics of PWS. As a result, muscle mass is decreased by 25-37%, which might explain partly the weakness and hypotonia. However, there are also structural and functional muscle abnormalities, and cortical motor areas are hypo-excitable in PWS patients. Moreover, disuse as result of decreased activity in PWS could also contribute. GH treatment positively influences body composition, but does not normalize it. Training could prevent disuse and improves body composition. Therefore GH treatment and training will probably enhance one another.

Validation of a simple method for measuring cranial deformities (Plagiocephalometry)

Craniofacial measuring is essential for diagnosis or evaluation of growth and therapies. Skull deformities in children are mainly caused by craniosynostosis or by external pressure in positional skull deformations. Traditional anthropometry does not sufficiently analyze craniofacial shape. In computed tomography (CT) scanning, radiation loads are considerable. Both CT and magnetic resonance imaging (MRI) scanning require anaesthesia in children for accurate imaging, due to their long acquisition time. This makes CT and MRI unsuitable for long term follow-up of pediatric patients unless there is a compelling reason. Other noninvasive three-dimensional (3D) surface scanners still have limited practical use. Van Vlimmeren et al6 presented plagiocephalometry (PCM) as a simple and versatile instrument to quantify skull deformities with high intrarater and interrater reliability, but no comparison was made with the actual skull shape. At the Erasmus University Medical Center Rotterdam, Sophia Childrens Hospital PCM was compared to 3D-CT scanning in 21 children with craniosynostosis early in life. The PCM ring proved to fit closely to the skin with mean differences less than 1 mm (P < 0.05). The shape of the PCM ring was not significantly changed when taken off the head (P > 0.05). Finally, no significant differences are shown between measurements on the skull (CT-scan) and PCM ring off the head (P > 0.05). This study proves that PCM is a reliable method for analysis of skull deformities. The measurements are in agreement with 3D-CT scanning as golden standard. Although only 2-dimensional measurements are performed by PCM, the combination of simplicity, reliability, and validity make it a promising tool for daily practice.

Functional, motor developmental, and long-term outcome after the component separation technique in children with giant omphalocele: A case control study

BACKGROUND/PURPOSE The objective of this study was to evaluate the long-term functional and motor development and abdominal muscle quantity in children operated on for giant omphalocele (GOC) with the Component Separation Technique (CST). METHODS Between 2004 and 2007, CST was applied in eleven consecutive infants with GOC. Eight underwent ultrasound of the abdominal wall and muscles, assessment of functional and motor development using the Movement Assessment Battery for Children, 2nd Edition (M-ABC-2), and an observational physical examination focused on possible abnormalities in stature and movements related to GOC. Findings were compared with those in age-matched controls. The parents filled in a questionnaire on the childrens functioning in daily life. RESULTS The mean age at evaluation was 71 months (range, 42-141 months) with a median time of follow-up of 54 months (range, 38-84 months). Ultrasound of the abdominal wall muscles showed normal muscle thickness. In seven of the eight children, a rectus diastasis was seen without any protrusion. The MABC-2 was within the normal range, and stature and motor coordination did not differ from those in controls. CONCLUSIONS After 4.5 years, these children show normal thickness of all abdominal wall muscles and motor function within the normal range, despite a rectus diastasis. The CST seems to be a promising closure technique for GOC.

Objective evaluation of muscle strength in infants with hypotonia and muscle weakness.

The clinical evaluation of an infant with motor delay, muscle weakness, and/or hypotonia would improve considerably if muscle strength could be measured objectively and normal reference values were available. The authors developed a method to measure muscle strength in infants and tested 81 typically developing infants, 6-36 months of age, and 17 infants with Prader-Willi Syndrome (PWS) aged 24 months. The inter-rater reliability of the measurement method was good (ICC=.84) and the convergent validity was confirmed by high Pearsons correlations between muscle strength, age, height, and weight (r=.79-.85). A multiple linear regression model was developed to predict muscle strength based on age, height, and weight, explaining 73% of the variance in muscle strength. In infants with PWS, muscle strength was significantly decreased. Pearsons correlations showed that infants with PWS in which muscle strength was more severely affected also had a larger motor developmental delay (r=.75).

Response to Pediatric Physical Therapy in Infants With Positional Preference and Skull Deformation

Background Pediatric physical therapy seems to reduce skull deformation in infants with positional preference. However, not all infants show improvement. Objective The study objective was to determine which infant and parent characteristics were related to responses to pediatric physical therapy in infants who were 2 to 4 months old and had positional preference, skull deformation, or both. Design This was a prospective cohort study. Methods Infants who were 2 to 4 months old and had positional preference, skull deformation, or both were recruited by pediatric physical therapists at the start of pediatric physical therapy. The primary outcome was a good response or a poor response (moderate or severe skull deformation) at 4.5 to 6.5 months of age. Potential predictors for responses to pediatric physical therapy were assessed at baseline with questionnaires, plagiocephalometry, and the Alberta Infant Motor Scale. Univariate and multiple logistic regression analyses with a stepwise backward elimination method were performed. Results A total of 657 infants participated in the study. At follow-up, 364 infants (55.4%) showed a good response to therapy, and 293 infants (44.6%) showed a poor response. Multiple logistic regression analysis resulted in the identification of several significant predictors for a poor response to pediatric physical therapy at baseline: starting therapy after 3 months of age (adjusted odds ratio [aOR]=1.50, 95% confidence interval [95% CI]=1.04–2.17), skull deformation (plagiocephaly [aOR=2.64, 95% CI=1.67–4.17] or brachycephaly [aOR=3.07, 95% CI=2.09–4.52]), and a low parental satisfaction score (aOR=2.64, 95% CI=1.67–4.17). A low parental satisfaction score indicates low parental satisfaction with the infants head shape. Limitations Information about pediatric physical therapy was collected retrospectively and included general therapy characteristics. Because data were collected retrospectively, no adjustment in therapy for individual participants could be made. Conclusions Several predictors for responses to pediatric physical therapy in infants who were 2 to 4 months old and had positional preference, skull deformation, or both were identified. Health care professionals can use these predictors in daily practice to provide infants with more individualized therapy, resulting in a better chance for a good outcome.

Insufficient vitamin D supplement use during pregnancy and early childhood: a risk factor for positional skull deformation

Vitamin D insufficiency during pregnancy is associated with disturbed skeletal homeostasis during infancy. Our aim was to investigate the influence of adherence to recommendations for vitamin D supplement intake of 10 μg per day (400 IU) during pregnancy (mother) and in the first months of life (child) on the occurrence of positional skull deformation of the child at the age of 2 to 4 months. In an observational case-control study, two hundred seventy-five 2- to 4-month-old cases with positional skull deformation were compared with 548 matched controls. A questionnaire was used to gather information on background characteristics and vitamin D intake (food, time spent outdoors and supplements). In a multiple variable logistic regression analysis, insufficient vitamin D supplement intake of women during the last trimester of pregnancy [adjusted odds ratio (aOR) 1.86, 95% (CI) 1.27-2.70] and of children during early infancy (aOR 7.15, 95% CI 3.77-13.54) were independently associated with an increased risk of skull deformation during infancy. These associations were evident after adjustment for the associations with skull deformation that were present with younger maternal age and lower maternal education, shorter pregnancy duration, assisted vaginal delivery, male gender and milk formula consumption after birth. Our findings suggest that non-adherence to recommendations for vitamin D supplement use by pregnant women and infants are associated with a higher risk of positional skull deformation in infants at 2 to 4 months of age. Our study provides an early infant life example of the importance of adequate vitamin D intake during pregnancy and infancy.

Is Motor Performance in 5.5-Year-Old Children Associated with the Presence of Generalized Joint Hypermobility?

OBJECTIVE To determine the prevalence of generalized joint hypermobility (GJH) in Dutch children aged 5.5 years, and to examine the association between GJH and motor performance and development over time. STUDY DESIGN A prospective cohort of 249 children was recruited. GJH was assessed with the Beighton test at age 5.5 years. Motor performance was evaluated at age 2.0 years using the Bayley Scales of Infant Development, Second Edition and at age 5.5 years using the Movement Assessment Battery for Children-Second Edition (subscore categories: manual dexterity, aiming and catching, and static and dynamic balance). RESULTS In 249 children, the prevalence of GJH, defined by the Beighton test score, was 34.1% for a score ≥ 4, 22.5% for a score ≥ 5, and 16.5% for a score ≥ 6. No significant association was found between GJH and total motor performance. Manual dexterity in girls (Beighton score ≥ 4) was positively associated with higher level of motor performance (β [SE] = 0.38 [0.17]; P = .028), ranging from +0.04 SD to +0.72 SD, even after correction for covariates. A significant interaction between GJH and body mass index (BMI) growth was found, indicating that the effect of GJH on the rate of development of motor performance declines with increasing BMI growth (β = 0.05 [0.02]; P = .031). CONCLUSION In this healthy pediatric cohort, GJH was present in one-third of the sample, and no significant association was found between GJH and total motor performance. The effect of GJH on the rate of development of motor performance appears to decline with increasing BMI growth. Longitudinal prospective studies are recommended to detect influences of GJH on motor performance over time, as well as the influence of body composition and Beighton cutoff points.