Magdalena M. Boere-Boonekamp

Swaddling: A Systematic Review

Swaddling was an almost universal child-care practice before the 18th century. It is still tradition in certain parts of the Middle East and is gaining popularity in the United Kingdom, the United States, and the Netherlands to curb excessive crying. We have systematically reviewed all articles on swaddling to evaluate its possible benefits and disadvantages. In general, swaddled infants arouse less and sleep longer. Preterm infants have shown improved neuromuscular development, less physiologic distress, better motor organization, and more self-regulatory ability when they are swaddled. When compared with massage, excessively crying infants cried less when swaddled, and swaddling can soothe pain in infants. It is supportive in cases of neonatal abstinence syndrome and infants with neonatal cerebral lesions. It can be helpful in regulating temperature but can also cause hyperthermia when misapplied. Another possible adverse effect is an increased risk of the development of hip dysplasia, which is related to swaddling with the legs in extension and adduction. Although swaddling promotes the favorable supine position, the combination of swaddling with prone position increases the risk of sudden infant death syndrome, which makes it necessary to warn parents to stop swaddling if infants attempt to turn. There is some evidence that there is a higher risk of respiratory infections related to the tightness of swaddling. Furthermore, swaddling does not influence rickets onset or bone properties. Swaddling immediately after birth can cause delayed postnatal weight gain under certain conditions, but does not seem to influence breastfeeding parameters.

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.

Ultrasonographic screening for developmental dysplasia of the hip in infants. Reproducibility of assessments made by radiographers.

We studied the reproducibility of ultrasonographic screening examination of the hip when read by diagnostic radiographers. In order to determine interobserver variability, 200 ultrasonograms were classified according to Grafs method by five observers (four radiographers and one radiologist). The kappa values for interobserver variability indicated moderate agreement (kappa 0.47) for the exact Graf classification and substantial agreement (kappa 0.65) for the classification of normal (type I) versus abnormal (type IIa-IV). Agreement was significantly different for normal, immature and abnormal hips. Comparison of the findings in our interobserver study with existing information based on other examinations and treatment revealed that only a small number of infants with mildly dysplastic hips would have been typed as normal by some observers as a result of observer variability. In conclusion, the interobserver agreement on the ultrasound assessment of the hip was good enough for screening purposes. Observer variability did not result in any severe cases being missed.

Kansrijke elementen in de preventie van overgewicht bij jonge kinderen: voldoende slaap en een gezaghebbende opvoeding.

SamenvattingMeer kennis van risicogroepen en determinanten van overgewicht en hoe deze met elkaar samenhangen is nodig, zodat effectieve elementen voor preventie en behandeling duidelijk worden. In dit artikel worden enkele factoren beschreven die kunnen bijdragen aan het voorkomen, stabiliseren of verminderen van overgewicht. Uit een review blijkt dat bij kinderen in alle leeftijdscategorieën een korte slaapduur gerelateerd is aan een verhoogd risico voor overgewicht en er is voldoende evidentie voor een dosis-effectrelatie. De prevalentie van korte slaapduur neemt toe en dit loopt parallel aan de dramatische toename in de prevalentie van overgewicht en obesitas. Ouders moeten worden aangemoedigd om jonge kinderen op tijd naar bed te brengen, zodat ze minimaal 10 tot 11 uur slapen per nacht. Deze interventie lijkt een belangrijke en relatief goedkope strategie om gewichtsproblemen bij kinderen te helpen voorkomen. Een tweede belangrijke determinant is een televisie/computer op de slaapkamer van het jonge kind.Tenslotte hangt opvoedingsstijl samen met overgewicht en obesitas. Een gezaghebbende opvoedingsstijl betekent sensitief en responsief opvoeden en tegelijkertijd rekening houden met het vermogen tot zelfregulatie en -controle van het kind. Een gezaghebbende opvoedingsstijl is beschermend, terwijl een restrictieve en een permissieve, verwaarlozende stijl de kans op overgewicht en obesitas vergroten.SummaryMore knowledge seems necessary about risk groups and determinants of overweight and obesity and how these are entangled in order to be able to prevent and treat them effectively. In this article factors that either may prevent, stabilize or reduce overweight are described.We conclude that there is strong evidence for a doseresponse relationship between short sleep duration and excess bodyweight in young children (and adolescents). Short sleep duration is becoming increasingly prevalent in children and this trend has paralleled the dramatic increase in the prevalence of obesity. Sleep is important for understanding childhood weight problems. Parents should be encouraged to put their young children to bed early enough, so that they can sleep at least 10 to 11 hours a night.This intervention may present an important and relatively low-cost strategy to reduce childhood weight problems. A second important determinant is the presence of a television/computer in a young child’s sleeping room. Lastly, research into childrearing styles and practices demonstrates the importance of an authoritative child rearing style, which is defined as high sensitivity of the caregiver towards the child combined with realistic expectations concerning the possibility of self-control of the child. A restrictive child rearing style defined as too low sensitivity and a permissive or neglective style increases the risk of overweight and obesity.

Screening for developmental dysplasia of the hip

The success rates of screening programmes for Developmental Dysplasia of the Hip (DDH) vary widely. Studies on screening programmes for DDH based on a Medline search for the years 1966–1997 are reviewed. The percentage treated in most studies, especially those using ultrasound, are high and suggest substantial over-treatment. Neonatal clinical screening has the best results, but programme effectiveness increases when this is combined with secondary screening of the high-risk population. The extra costs are compensated by reduced treatment costs of late-diagnosed cases.

HElmet therapy Assessment in infants with Deformed Skulls (HEADS): protocol for a randomised controlled trial

BackgroundIn The Netherlands, helmet therapy is a commonly used treatment in infants with skull deformation (deformational plagiocephaly or deformational brachycephaly). However, evidence of the effectiveness of this treatment remains lacking. The HEADS study (HElmet therapy Assessment in Deformed Skulls) aims to determine the effects and costs of helmet therapy compared to no helmet therapy in infants with moderate to severe skull deformation.Methods/designPragmatic randomised controlled trial (RCT) nested in a cohort study. The cohort study included infants with a positional preference and/or skull deformation at two to four months (first assessment). At 5 months of age, all children were assessed again and infants meeting the criteria for helmet therapy were asked to participate in the RCT. Participants were randomly allocated to either helmet therapy or no helmet therapy. Parents of eligible infants that do not agree with enrolment in the RCT were invited to stay enrolled for follow up in a non-randomisedrandomised controlled trial (nRCT); they were then free to make the decision to start helmet therapy or not. Follow-up assessments took place at 8, 12 and 24 months of age. The main outcome will be head shape at 24 months that is measured using plagiocephalometry. Secondary outcomes will be satisfaction of parents and professionals with the appearance of the child, parental concerns about the future, anxiety level and satisfaction with the treatment, motor development and quality of life of the infant. Finally, compliance and costs will also be determined.DiscussionHEADS will be the first study presenting data from an RCT on the effectiveness of helmet therapy. Outcomes will be important for affected children and their parents, health care professionals and future treatment policies. Our findings are likely to influence the reimbursement policies of health insurance companies.Besides these health outcomes, we will be able to address several methodological questions, e.g. do participants in an RCT represent the eligible target population and do outcomes of the RCT differ from outcomes found in the nRCT?Trial registrationISRCTN18473161.

Implementation by simulation; strategies for ultrasound screening for hip dysplasia in the Netherlands

BackgroundImplementation of medical interventions may vary with organization and available capacity. The influence of this source of variability on the cost-effectiveness can be evaluated by computer simulation following a carefully designed experimental design. We used this approach as part of a national implementation study of ultrasonographic infant screening for developmental dysplasia of the hip (DDH).MethodsFirst, workflow and performance of the current screening program (physical examination) was analyzed. Then, experimental variables, i.e., relevant entities in the workflow of screening, were defined with varying levels to describe alternative implementation models. To determine the relevant levels literature and interviews among professional stakeholders are used. Finally, cost-effectiveness ratios (inclusive of sensitivity analyses) for the range of implementation scenarios were calculated.ResultsThe four experimental variables for implementation were: 1) location of the consultation, 2) integrated with regular consultation or not, 3) number of ultrasound machines and 4) discipline of the screener. With respective numbers of levels of 3,2,3,4 in total 72 possible scenarios were identified. In our model experimental variables related to the number of available ultrasound machines and the necessity of an extra consultation influenced the cost-effectiveness most.ConclusionsBetter information comes available for choosing optimised implementation strategies where organizational and capacity variables are important using the combination of simulation models and an experimental design. Information to determine the levels of experimental variables can be extracted from the literature or directly from experts.

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.