Cranial Molding Deformity: Evidence for Prevention and Treatment in the NICU
By: Elizabeth Lynch, SPT
Background
I first became interested in the topic of cranial molding after completing my 2nd year Research Experience with Dana McCarty, PT, DPT, PCS, C/NDT in the Neonatal Intensive Care Unit at Duke Hospital. In Evidence-Based Practice II, I had the opportunity to explore the literature related to cranial molding interventions to develop a Critically Appraised Topic on the following clinical question: “For a preterm infant in the neonatal intensive care unit with cranial molding deformity, is a cranial molding orthotic device or a positioning program more effective for correcting head shape to achieve greater symmetry?”
Based on my search results for this assignment, I ended up focusing only on the cranial cup as an orthotic device for preterm infants in the NICU, as cranial molding helmets are not indicated for children less than 4 months of age.1 While my CAT primarily discussed a single device, my capstone project incorporates the available information and evidence for numerous other head shaping devices that are utilized in neonatal intensive care units, particularly with premature infants.
Project Overview
Currently, there is minimal research of good quality that focuses on cranial molding interventions specifically for premature infants in the NICU setting. I learned this firsthand through the completion of my Critically Appraised Topic for EPB II. Through discussing this topic with my project advisor, Dana, I learned that this lack of evidence is a real problem in NICUs across the country, and facilities often end up selecting whichever head shaping devices are presented to them by equipment representatives, even if there is inadequate research to support the effectiveness of these products. In an attempt to address this issue, I composed a literature review of the current available evidence regarding cranial molding interventions in the NICU, as well as a powerpoint to be delivered as an inservice presentation during my final clinical rotation. I will have the pleasure of working in inpatient pediatrics at Duke Hospital for my last rotation, so it will be an excellent setting in which to share my capstone products. I also developed a quick reference guide for the most widely utilized devices based on a national survey of neonatal clinicians that was recently conducted by McCarty et al.2 My hope is that this reference guide will help meet a need for NICU clinicians by describing the various head shaping interventions that are currently available, as well as offering a review of the current best evidence that exists on this topic. With this information, they will be better able to select patient-appropriate cranial molding interventions for each individual baby.
Capstone Products
Product Evaluation Tool
I developed the following survey as an evaluation tool for my Quick Reference Guide of cranial molding intervention devices in the NICU. It was created and disseminated via surveymonkey and is in the process of being completed by my capstone advisor, committee members, additional pediatric clinicians, and classmates who intend to pursue pediatrics and took PHYT 880 (Child and Family Assessment and Intervention) with me in the fall of 2016. Feedback provided by this survey will help me to make continued improvements to the guide prior to distributing it to clinicians at Duke Hospital during my final clinical rotation.
https://www.surveymonkey.com/r/MGBQJ9H
While creating my powerpoint presentation as well as my quick reference guide, I used information from various resources to make the formatting of these products more appealing to their audience. For the powerpoint in particular, I attempted to minimize the text on each slide and make good use of images that contribute directly to the intended message of the slide. The slides that have the greatest amount of text are bulleted summaries of relevant research studies, and I chose to include this information so that if I were to provide this document as a printed resource, then the take-home message of these articles would be evident to the reader. Furthermore, since my presentation will be delivered to experienced clinicians at Duke Hospital, I did not include as much background content as I would if my presentation were intended for entry level DPT students. Instead, I chose to focus more of my presentation time on specific intervention devices with which all clinicians may not be familiar. For the quick reference guide, my goal was to create a one-page document (front and back) that incorporated the most important details of each device without being cluttered. Though it was a bit challenging to select the information to prioritize, I received feedback from multiple individuals that both of these products have a visually appealing format and are well organized. Reviewers also indicated that the images used for both documents are helpful for facilitating understanding of the topic.
Self-Reflection
Prior to beginning my project, I developed a few personal learning objectives as follows:
- To become familiar with the current available evidence and appropriate use of various head shaping interventions, as demonstrated through the development of an evidence table
- To improve my ability to synthesize information from various sources, as demonstrated through the development of a literature review
- To build relationships with pediatric physical therapists who can offer guidance and mentorship in the future, as demonstrated by interactions with my committee members over the course of the project
I feel as though I have been fairly successful in meeting these learning objectives through the completion of this project. I now have a better understanding of the current state of the literature in relation to this topic, and I realize that it is a much-needed area of research for the future. Knowing that there are many additional cranial molding devices out there that are less widely utilized, I hope to continue expanding my knowledge of these interventions over the course of my career. In addition, I now feel more confident in my ability to review and synthesize literature from various sources, and I learned some work strategies about myself in the process. For example, my typical preference is to read and highlight articles on my computer; however, for this particular project with a larger number of sources to review, I was more efficient after printing the articles and having physical copies to help me organize the information. I am glad to have developed strategies such as this for continuing to grow in my research skills.
The area in which I struggled most over the course of this project was asking for help and advice from others. I knew that this process of working alongside an advisor and committee members who were not physically present would be a challenge for me, as I often feel like my questions or requests for feedback are burdensome for busy clinicians who already have so much on their plate. While I have no problem asking questions in a classroom/clinic setting or working as a team on group projects, reaching out via email for something that primarily benefits me feels like more of an intrusion into someone else’s time. However, I am realizing that most people are happy to share their advice and experience with students who are following in their footsteps, and I plan to do the same for others as well. Overall, I am pleased with the products that were developed for this project, and I hope that they will be useful to me and other therapists in the future.
Acknowledgements
I am incredibly grateful for the advice and support of my advisor, Dana McCarty, PT, DPT, PCS, C/NDT, and my committee members, Marian Stein, PT, DPT and Jenny Peat, MSPT, NTMC, in the development of these capstone products. I appreciate all of the time you spent reviewing each component of my project and for the valuable feedback you shared, as well as your patience with my numerous emails. Thank you all for loving babies and physical therapy alongside me!
I also want to thank Chloe Smith, Brennan Visser, Jessie Risen, and Julie Coats for their willingness to complete an evaluation survey of my products as present and future pediatric clinicians; Prue Plummer, PhD, PT for her teaching and feedback in EBP II to greatly improve my research skills and get me started on the right foot with this topic; and UNC DPT as a whole for providing an excellent educational experience over the past 3 years.
References
- Wilbrand J, Schmidtberg K, Bierther U. Clinical Classification of Infant Nonsynostotic Cranial Deformity. The Journal of Pediatrics. 2012;161(6):1120-1125.e1. doi:10.1016/j.jpeds.2012.05.023.
- McCarty DM, Eberbach M, Peat J. Therapeutic Practices for Cranial Molding Deformity in the Neonatal Intensive Care Unit: A National Survey. Manuscript in preparation.
9 Responses to “Cranial Molding Deformity: Evidence for Prevention and Treatment in the NICU”
Elizabeth Lynch
Debbie,
Thank you so much for taking the time to look over my capstone and share your feedback. Yes, it was wonderful to learn from Dana throughout this project! I really appreciate your encouraging words, and I am happy to hear that you learned some new information from my products as well! I was pleased with how the quick reference guide turned out in particular, and I do hope that it will be a beneficial resource that I can distribute in the future. Thank you again for your comments and for the wealth of pediatric knowledge and experience you’ve shared over the past 3 years!
Elizabeth
Elizabeth Lynch
Whitney,
Thanks for reviewing my project and for your comments. I am very glad to hear that you found this information helpful to supplement what we learned in class a while back. It seems like cranial molding helmets are much more widely known as an intervention for CMD, but maybe if we had a more effective method of preventing and treating this condition earlier on with some of the devices included in my project, we could reduce the need for more costly helmet therapy down the road. Thanks again for your feedback!
Elizabeth
Elizabeth Lynch
Hi Jess,
Thanks for the time you spent reviewing my project and proving such great feedback. I agree that having samples of each device would be a beneficial addition to my inservice presentation, though this is not a consideration that I had thought of prior to reading your comments. I really appreciate you making this suggestion, and hopefully I will have the opportunity to obtain some of these devices between now and then. In terms of the timing for obtaining cranial measurements, I am not aware of any specific protocols that exist, though I would not be surprised if they do. What I can tell you are a few of the timelines that were used in some of the studies I reviewed. In the study by McCarty et al, cranial index measurements of preterm infants were obtained at three different time points during hospitalization: 2 weeks chronological age, 32-34 weeks post-menstrual age, and within 1-2 weeks before discharge. (1) However, since the infants were born at different gestational ages and remained in the hospital for different amounts of time, this methodology does not provide equivalent time intervals between measurements for each subject. In the study by Knorr et al, cranial measurements were taken at baseline upon enrollment in the study and at hospital discharge. (2) In the study by DeGrazia et al, cranial measurements were only obtained at discharge. (3) I would also be interested to know if hospitals do have specific protocols for the timing of measurements, as I agree that this strategy would be helpful for determining which devices are working well for which infants, especially since the evidence is so scarce at this point in time. Thanks again for your comments!
Elizabeth
1. McCarty D, Peat J, Malcolm W, et al. Dolichocephaly in Preterm Infants: Prevalence, Risk Factors, and Early Motor Outcomes. American Journal of Perinatology. 2016;34(04):372-378. doi:10.1055/s-0036-1592128.
2. Knorr A, Gauvreau K, Porter C, Serino E, DeGrazia M. Use of the Cranial Cup to Correct Positional Head Shape Deformities in Hospitalized Premature Infants. Journal of Obstetric, Gynecologic & Neonatal Nursing. 2016;45(4):542-552. doi:10.1016/j.jogn.2016.03.141.
3. DeGrazia M, Giambanco D, Hamn G, Ditzel A, Tucker L, Gauvreau K. Prevention of Deformational Plagiocephaly in Hospitalized Infants Using a New Orthotic Device. Journal of Obstetric, Gynecologic & Neonatal Nursing. 2015;44(1):28-41. doi:10.1111/1552-6909.12523.
Debbie Thorpe
Hi Elizabeth
I thoroughly enjoyed viewing your capstone project and learned a lot about cranial molding deformity. Having Dana as your advisor was a real plus!! I had no idea all of the adaptive equipment that was available for parents to help treat this deformity!! I am sure that the clinicians at Duke will be grateful for the latest evidence and the resources guide when you present to them later this summer. You are well on your way to being an evidenced-based pediatric PT:) I am sure that Dana will be glad to ask permission to use your reference guide in her teaching. Very professional presentation and project. Good luck on your LAST clinical rotations!
Best
Debbie
Whitney Huryta
Hi Elizabeth,
When we had our pediatrics materials in class, I remember that we briefly discussed options for various tools for infants in order to help with cranial molding. However, I never felt confident in how I would go about making that recommendation. However, your materials offer some great insight in comparing the products and deciding which ones would be appropriate for a particular child. Overall, I have to agree with my classmates who posted above. You did an excellent job with a difficult subject and I wish you good luck in your future presentation this summer!
Elizabeth Lynch
Brennan & Jessie,
Thank you for taking the time to review my capstone project and for your encouraging comments. I’m glad to know that my products were a source of beneficial information about CMD and its interventions in the NICU, even though my clinical encounters with this condition have been minimal thus far. I have really enjoyed learning a lot about pediatrics from you both this year, and congratulations on all the hard work you’ve put in to improving the physical therapy experience for our kiddos!
Elizabeth
Jessica Reynolds
Hi Elizabeth,
Excellent presentation! I thought your content was well organized, and it was very helpful to see images of the different types of deformities and the different devices used to address them. It was interesting to learn that the Back to Sleep campaign correlated with an increase in CMD!
It was also surprising to hear about the variety of instruments used and the limited amount of quality evidence. You mentioned the importance of patient centered care and figuring out what will work best for each individual baby. I’m curious how often the NICUs typically measure for changes in CMD, since regular monitoring might allow the nurses and therapists to determine which instruments are working for the child and which aren’t. Have you come across a typical timing protocol for measurements, either at Duke or other NICUs?
Again, excellent work! I really enjoyed learning about CMD from your presentation, and it seems that the information presented addresses a real need for this population. If possible, it would be awesome if you could have hands on samples for each of these devices when presenting at your clinical rotation. The pictures are excellent, and I think it helps even more to get a feel for each device hands on, especially if some of them are different from the ones that Duke clinicians regularly use.
Best of luck with your presentation this summer. I’m sure it will be great!
Jessie Risen
Hey Elizabeth,
Thank you for allowing me to have a sneak peak at your reference guide for CMD. I personally do not have experience in the NICU setting but have seen several patients with CMD and torticollis in my prior 10 years of experience in the outpatient pediatric setting. I really appreciated slide #11 in your presentation with the image of the infant and the cycle of CMD and torticollis. In my experience as an outpatient pediatric PT, I always felt the same way as this photo which depicts torticollis and CMD like the “chicken before the egg?” theory. Your presentation and quick reference guide are well organized and informative and should be a welcomed opportunity for continued professional development and current evidence to the other PT professionals in your upcoming Duke NICU rotation. I am so glad that I had the opportunity to get to know you and work with you a bit, in the school setting during your rotation here with your CI. Congratulations on a project well done, and I wish you luck in your future as a pediatric physical therapist!
-Jessie
Brennan Visser
Elizabeth,
My experience with CMD is limited to observation of a PT in the NICU, so I found your presentation very helpful! I had no idea that it affects up to 48% of newborn infants. As one of the people that reviewed your quick reference guide, I thought it was a great resource, but knowing very little on the topic I wanted more information. So I was thrilled to see you had also completed a literature review and PowerPoint presentation. Those were very helpful in providing more comprehensive and detailed information, so that now I feel like I could better utilize the reference guide if I were to be in the NICU setting. Like many areas of pediatrics, there is much more research to be done. You did a fantastic job not only synthesizing the available evidence, but also seeking out clinicians who have experience with CMD. Evidence-based practice is not just the integration of best available research, but also clinical expertise, and I think you did a wonderful job of incorporating both into your capstone.
Great job!
Brennan