Background and Purpose:
Premature infants who have prolonged stays in the neonatal intensive care unit (NICU) are prone to developing positional plagiocephaly, also referred to as deformational plagiocephaly.1 Premature infants in the NICU are at increased risk for developing positional plagiocephaly due to the malleability of the neonate skull, weight of gravity against the infant, and unnatural, sustained supine positioning in the NICU.3 An increase in the prevalence of deformational plagiocephaly was detected after the American Academy of Pediatrics launched the “Back to Sleep Campaign” in 1994 to prevent Sudden Infant Death Syndrome (SIDS) and suffocation.4 While the number of infant deaths related to SIDS and suffocation has decreased, cranial molding deformities have increased as infants spend increased time lying supine on firm surfaces.4 Infants in the NICU spend more time in supine than their healthy peers because their medically unstable condition may limit frequent repositioning and handling by nurses and caregivers.1 Positional plagiocephaly, left untreated, can lead to disruptions in parent-child bonding, motor developmental, delay and motor asymmetries.1,3
While the prevalence of the positional plagiocephaly in the NICU setting is well documented, there is no standard of care for preventing or treating positional plagiocephaly in the NICU. Various positioning devices including, water-bed mattresses, foam mattress, and gel pillows, have been employed with inconsistent success and limited evidence.2 Nursing education regarding frequent repositioning and physical therapy have also been used to prevent positional plagiocephaly, again with low-quality evidence to support their efforts.2 There is a need for an evidence-based standard of care to prevent and treat positional plagiocephaly in the NICU setting.
I first became of aware of the prevalence of positional plagiocephaly in the NICU through the research performed by my advisor, Dana McCarty PT, DPT, PCS, C/NDT. I began my journey delving into this topic in Evidence Based Practice II when I chose to answer the question: “Is nursing and caregiver education on cranial molding deformities for neonatal ICU patients more effective than the use of the cranial cup for preventing plagiocephaly, measured as less than 3.5 on cranial vault asymmetry index?”
My CAT primarily focused on the cranial cup device, and ultimately led me to realize that there is very little evidence regarding preventing and treating positional plagiocephaly in the NICU. There is much more research in older infants, specifically after 7 weeks of age, but far less research conducted on term and preterm infants immediately after birth. My capstone project focuses on the literature that is available regarding deformational plagiocephaly immediately following birth in the NICU setting. I have developed a parent handout for distribution to parents of infants in the NICU that provides general information about deformational plagiocephaly and what parents can do to help. I have also updated a resource guide, originally developed by Elizabeth Lynch, PT, DPT in 2017. The resource guide includes devices used in the NICU to prevent and treat deformational plagiocephaly and the evidence that has been conducted to support these devices. Finally, my literature review will be used to develop the ‘introduction’ and ‘literature review’ components of a manuscript by Dana McCarty, entitled, “Neonatal Therapists’ Perspectives on Cranial Molding Deformity: An overview of current Status and Best Practice.”
Capstone Products:
Cranial Molding Deformity Parent Handout
Evaluation Tool:
To evaluate the effectiveness and quality of my parent handout, I have developed a survey that is in the process of be completed by my advisor, committee members, and classmates that completed Child and Family Assessment in the Fall of 2019.
https://www.surveymonkey.com/r/BM7KLMQ
Self-Reflection:
My personal learning objectives when beginning this project were as follows:
- Understand the evidence-based physical therapy techniques, orthotic products, and parent education that contribute to the prevention and treatment of cranial molding deformities.
- Develop the skills needed for producing effective educational material for parents of various literacy levels.
- Learn to appropriately and effectively incorporate feedback from committee members.
I feel as though I met those learning objectives and learned more about infant positioning devices than I ever thought possible! When first beginning the project, I was too focused on the cranial cup because that is the device that has the most evidence to support its use. I was also reporting research for older infants, 7 weeks and older. With the guidance of my advisor and committee, I was able to refocus my project on neonates in the NICU and include the research, or lack thereof, for positioning devices, frequent position changes, nursing education, and parent education.
I am very happy with how my project turned out and am excited for my classmates to learn more about cranial molding deformities in the NICU!
Acknowledgements:
I would like to thank my advisor, Dana McCarty, and committee members, Cara Drvol and Elizabeth Lynch for providing me with feedback and guidance throughout this process! This has been a great learning experience both in learning about cranial molding deformities in the NICU and in working as a team member in the creation of various products.
References:
- Knorr A, Giambanco D, Staude MV, et al. Feasibility and safety of the preemie orthotic device to manage deformational plagiocephaly in extremely low birth weight infants. Adv Neonatal Care. 2019;19(3):226-235. doi:10.1097/ANC.0000000000000585
- DeGrazia M, Giambanco D, Hamn G, Ditzel A, Tucker L, Gauvreau K. Prevention of deformational plagiocephaly in hospitalized infants using a new orthotic device. J Obstet Gynecol Neonatal Nurs. 2015;44(1):28-41. doi:10.1111/1552-6909.12523
- McCarty DB, Peat JR, Malcolm WF, Smith PB, Fisher K, Goldstein RF. Dolichocephaly in preterm infants: prevalence, risk factors, and early motor outcomes. Am J Perinatol. 2017;34(4):372-378. doi:10.1055/s-0036-1592128
- Baird LC, Klimo P, Flannery AM, et al. Congress of Neurological Surgeons Systematic Review and Evidence-Based Guideline for the Management of Patients With Positional Plagiocephaly: The Role of Physical Therapy. Neurosurgery. 2016;79(5):E630-E631. doi:10.1227/NEU.0000000000001429
6 Responses to “Preventing and Treating Cranial Molding Deformities in the Neonatal Intensive Care Unit”
karlak
Bethany,
GREAT job on your capstone! At first I was interested in doing a project on cranial molding in infants in the NICU, so it was fun to read yours! I am very surprised by the little research that exists for infants younger than 7 weeks. In my mind, this is a great time to optimize positioning of their head for the prevention of deformities. With that said, I understand that in many of these cases there are a lot of medical concerns, so sometimes using devices or positioning can be difficult. However, creating easy to use devices for babies in the NICU and ensuring they are working is a big part of their health, especially after they leave the NICU.
I am excited to see more research come out for preventing this in NICU babies, and I am hopeful that soon in our career this will a priority in their healthcare plan!
Awesome job on your products. The resources sheets you created are very well done and will be useful for clinician ( and me). You did an awesome job using “patient” language and keeping them clear! Great job! I cant wait to be a peer of yours as we become pediatric therapists!
Kristen Shumaker
Bethany,
First of all, I just want to commend you for such an impressive capstone and final literature review. I love being able to see your dedication and passion for pediatrics displayed through this final product and its contribution to your future as an amazing physical therapist for this population. I personally have not had any experience in working with many of these devices discussed throughout your review, thus I found this information very beneficial and something I can carry forward if every working with patients in patients in the NICU. Particularly, I found the cranial cup to be the most interesting, considering the research supporting its superiority, given it is custom-made to fit the individual head shape of each infant and is adjusted every two weeks to accommodate the growth of the infant’s head. Additionally, I find it interesting to compare this to the parent education that is imperative once the infant is discharged and the importance of teaching repositioning, safe-handling, and varying feeding positions. Thus, I think your Cranial Molding Deformities Parent Handout is such an amazing resource for parents. It does a great job of providing the information in layman’s terms and provides great images as a reference. Also, the quick reference guide of the various devices is another great tool as well that can certainly be utilized by other PTs and health care professionals. I know I will use it as reference guide if I ever find myself working with this population. Overall, you did an amazing job with this project, and all of your deliverables provide such useful information for us all as future clinicians. Great job!
Best,
Kristen
Katherine Lewis
Hi Bethany,
I found all of your capstone deliverables to be excellent! I think the Cranial Molding Deformity Parent Handout seems reasonable for individuals with low levels of health literacy to understand. I also think this handout provides a lot of important information without overwhelming parents. I also think the images depicting the different types of cranial molding deformities will be especially helpful for individuals who are not familiar with these conditions (particularly visual learners such as myself!). I also found your Device Resource Guide to be particularly informative and well organized! I personally really appreciated the inclusion of images as I have not had any experience working with infants in the acute care environment therefore many of these devices were unknown to me prior to viewing this document. It was interesting to see how many of these devices do not have evidence to support their use therefore I think this guide also does a good job illustrating the additional research necessary in this area.
Deborah Thorpe
Bethany
I really enjoyed reading your project and learned a lot more about cranial molding deformity! Your literature review was very complete and the Resource Guide is very informative with great picture references. These resources will be very valuable to PTs working in the NICU.
Fantastic effort on this capstone project!
Debbie
Amy Collins
Bethany,
I am so impressed by your Capstone project products! The Caregiver Cranial Molding Deformity Handout is an excellent resource for parents, especially new parents who may have little background on infant health or low health literacy. The diagram depicting the three types of cranial molding deformity is a great visual, and the written information provided is both concise and informative. The succinct bullets for what to do as parents provide easy-to-follow instructions, and including the warning to place infants on their backs to sleep to prevent sudden infant death syndrome improves safety awareness and education.
I am also really impressed by your device resource guide; there were so many body and head positioning devices that I was previously unaware of. I only had a few days during my acute care clinical rotation in the neonatal intensive care unit (NICU), but I saw several cases of plagio- and brachycephaly and several of these devices would have likely helped prevent a few of these. The Flo Fluidized Neonatal Positioner is one of the devices I had previously never heard of, but from your resource guide description, it appears similar in concept to the powered air pressure redistribution mattresses often used in adult intensive care units. These specialty mattresses remind me of air beds, and have proven effective at preventing pressure ulcer incidence, a result of areas of heightened and localized pressure. Although I’m not sure whether I will be working with the pediatric population upon graduation, I have spent the past couple of weeks nannying a four-month-old infant with a bald spot on the back of her head (which makes me want to further increase her tummy time). Your Capstone’s literature review provides me and other physical therapists, nurses, and caregivers with excellent information and references for cranial molding deformities that are relevant to all parents and caregivers.
Great job! Your Capstone is comprehensive, evidence-based, useful, and an excellent set of resources. I’m so proud to have such an amazing classmate, colleague, and friend, and I can’t wait to continue learning from you and asking your advice whenever I work with pediatric patients!
Jennifer Tompkins
Bethany,
I found your Capstone project very interesting and unique. The cranial molding deformity handout is quite practical and useful. The pictures are great for parents, as they don’t often see the same deformity that I see as a clinician, but the pictures could assist PTs by providing increased information for varied learning styles.
I am curious if any of the devices you used are actually being used NICU’s, and if so, how would you find out? And, are any of these being used in the home after discharge? I have used the tortle cap, but families find it difficult to place properly and eventually abandon the use of this cap (in my clinical experience in the home). Congrats on completing your Capstone!