Child's Nervous System

https://doi.org/10.1007/s00381-019-04400-z

ORIGINAL ARTICLE

Safety and efficacy of independent allied healthcare professionals

in the assessment and management of plagiocephaly patients
Yahya Khormi 1 & Michelle Chiu 2,3 & Ronette Goodluck Tyndall 4 & Patricia Mortenson 5,6 & David Smith 7 &
Paul Steinbok 8,9

Received: 14 December 2018 / Accepted: 27 September 2019

# Springer-Verlag GmbH Germany, part of Springer Nature 2019

Abstract
Background The incidence of positional plagiocephaly has increased significantly over the last two decades, which has caused a service
delivery challenge for pediatric neurosurgeons. As a potential solution to the long waitlists for abnormal head shape, a plagiocephaly clinic
was established at BC Children’s Hospital (BCCH) in Vancouver, Canada. This clinic was supervised by an occupational therapist who
had been trained by a neurosurgeon to independently assess and manage patients with a referring diagnosis of positional plagiocephaly.
Objectives To determine the efficiency of the BCCH Plagiocephaly Clinic in the management of positional plagiocephaly patients and to
investigatetheclinic’sabilitytoappropriatelyidentifyandreferpatientswithcraniosynostosistopediatricneurosurgeonsforfurtherassessment.
Methods A retrospective chart review was conducted to identify patients who were assessed and managed at the BCCH
Plagiocephaly Clinic between 2008 and 2014. Data on patient demographics, head shape measurements, and treatment recom-
mendations were collected, and the BC Children’s neurosurgical database was cross-referenced to identify craniosynostosis cases
missed by the Plagiocephaly Clinic. A descriptive analysis of the clinic’s average wait times, severity of the patients’
plagiocephaly, and recommended interventions was conducted. In addition, the sensitivity and specificity of the clinic’s ability
to appropriately refer craniosynostosis patients to pediatric neurosurgery were calculated.
Results Of 1752 patients seen in the BC Children’s Plagiocephaly Clinic between 2008 and 2014, 66% of patients received counseling
about repositioning, 34% were referred for head banding, 19% were referred to physiotherapy for torticollis, and 1.4% were referred to the
BC Children’s Pediatric Neurosurgery Clinic for suspicion of craniosynostosis. The mean time from referral to first assessment by the
Plagiocephaly Clinic was 41 days, and time from referral by the plagiocephaly clinic to diagnosis of craniosynostosis by a pediatric
neurosurgeon was 8 days. Pediatric neurosurgeons requested imaging for 6 of the referred patients (25% ). The sensitivity and specificity
of the plagiocephaly clinic for referral of craniosynostosis patients to the Pediatric Neurosurgery Clinic were 100 and 99%, respectively.
Conclusion The BC Children’s Plagiocephaly Clinic is efficient and safe for the initial evaluation and treatment of patients with
positional plagiocephaly. The clinic’s model decreases wait times, appropriately manages patients with positional plagiocephaly,
screens for craniosynostosis with high sensitivity and specificity, and takes pressure off outpatient neurosurgical clinics. This
model for assessment of plagiocephaly could be considered in other medical centers.

Keywords Plagiocephaly clinic . Positional plagiocephaly . Craniosynostosis . Outpatient management

* Yahya Khormi 5
Department of Occupational Therapy, British Columbia Children’s
khormins@gmail.com Hospital, Vancouver, BC, Canada

6
1
Department of Occupational Science and Occupational Therapy,
Division of Neurosurgery, Department of Surgery, Faculty of University of British Columbia, Vancouver, Canada
Medicine, Jazan University, Gizan, Saudi Arabia
2 7
Division of Neurology, University of British Columbia, Department of Pediatrics, British Columbia Children’s Hospital,
Vancouver, BC, Canada Vancouver, BC, Canada
3
Department of Pediatrics, British Columbia Children’s Hospital, 8
Division of Pediatric Neurosurgery, University of British Columbia,
Vancouver, Canada Vancouver, BC, Canada
4
Division of Neurosurgery, Department of Surgery, University of
9
West Indies and University Hospital of West Indies, Department of Surgery, British Columbia Children’s Hospital,
Kingston, Jamaica Vancouver, BC, Canada

Background
Plagiocephaly is a common reason for referral to pediatric
neurosurgeons. It is characterized by an asymmetry of the
skull and may be caused by craniosynostosis (premature fu-
sion of the cranial bone sutures) or much more commonly
may be positional. Positional plagiocephaly is defined as a
deformation of the skull produced by extrinsic forces acting
on an intrinsically normal skull. The greatest amount of defor-
mation occurs in the first few months of life when the skull is
most malleable and when an infant spends the majority of time
lying on the back. Infants may also develop skull flattening in
the prenatal period due to positioning in utero [1–3].
While positional plagiocephaly does not affect brain devel-
opment, parents may be concerned with the cosmetic appear-
ance of their child’s head. In addition, it is essential to distin-
guish positional plagiocephaly from other head shape anom-
alies, especially craniosynostosis which may require surgical
management [4–7]. A medical professional can usually distin-
guish between positional plagiocephaly and craniosynostosis
through clinical examination. Rarely, an X-ray or CT head is
required to confirm a diagnosis of craniosynostosis and comes
with the downsides of radiation exposure, sedation, and finan-
cial costs to the healthcare system [4, 8, 9].
Positional plagiocephaly usually improves with conserva-
tive measures, such as appropriate caregiver counseling on
sleep positioning and tummy time, physiotherapy for treat-
ment of any associated torticollis, and growth over time
[10–12]. In patients who do not respond sufficiently, a
custom-made cranial molding orthotic may be used as a cos-
metic treatment option if parents desire, although recent re-
ports question the long-term efficacy [13–16].
The reported incidence of positional plagiocephaly has in-
creased dramatically in the last two decades [17] and a recent
Canadian study demonstrated that 47% of infants aged 7 to 12
weeks have some degree of positional plagiocephaly [18]. This
increase is likely due to the Back to Sleep campaign in 1992, which
recommended that infants be placed in a supine position during
sleep in order to reduce the incidence of sudden infant death syn-
drome(SIDS)[19–21].Otherriskfactorsfordevelopingpositional
plagiocephaly include multiple births, intrauterine constraint, pre-
mature birth, assisted delivery, torticollis, tummy time less than
three times per day, and slow motor development [1, 3, 22].
The number of referrals for abnormal head shape has cor-
respondingly risen in the past two decades at many centers
[23, 24], including the Pediatric Neurosurgery Clinic at BC
Children’s Hospital (BCCH). At BCCH, this caused a service
delivery challenge and increased the wait times for patients to
be seen by a pediatric neurosurgeon.
As a potential solution to this problem, the BC Children’s
Plagiocephaly Clinic was established in 2005, as a clinic run
independently by an occupational therapist (OT) with a specific
interest and expertise in positional plagiocephaly. This OT had
Childs Nerv Syst
been assessing patients with positional plagiocephaly who had
been referred for consideration of head banding by the pediatric
neurosurgeons. Prior to starting the new Plagiocephaly Clinic,
the OT received an additional 15-min training session from one
of the pediatric neurosurgeons (PS) at BCCH on how to differ-
entiate positional plagiocephaly from craniosynostosis on clinical
examination. The OT was advised to immediately refer patients,
who did not have a head shape typical of positional
plagiocephaly, to a pediatric neurosurgeon.
The Plagiocephaly Clinic was initiated as a half-day clinic
held once a week, with 0.1 FTE (full-time equivalent) of the
OT’s time assigned for the clinic. Referrals to the clinic came
primarily from family physicians and pediatricians, but occasion-
ally from pediatric craniofacial plastic surgeons. Referrals to the
Pediatric Neurosurgery Clinic for assessment of positional
plagiocephaly were directed to the Plagiocephaly Clinic. The
number of referrals to the Plagiocephaly Clinic rose rapidly. To
increase the clinic’s capacity in the most cost-effective way, a
part-time general pediatrician joined the clinic in 2011 after un-
dergoing similar training by the pediatric neurosurgeon.
The Plagiocephaly Clinic continues to be run independently
by an OT and general pediatrician with administrative support, as
required. Clinics are held once to twice a week in the BCCH
Occupational Therapy Department. The clinic offers group sem-
inars for families, which review the types of plagiocephaly, its
causes and risk factors, repositioning strategies with a focus on
safe sleep, indications for head banding, and outcomes of posi-
tional plagiocephaly. In addition, for each patient, there is a thor-
ough clinical assessment, including history of pregnancy, birth,
and general health; review of risk factors; visual assessment of
head shape and head measurements; and clinical screening for
craniosynostosis, torticollis, and delayed motor development.
There are a number of possible recommended intervention
options based on clinical assessment and parental preferences,
including:
(a) Counseling on repositioning, with a focus on safe sleep
(b) Cranial orthotic if appropriate given the patient’s age and
severity of plagiocephaly
(c) Referral to physiotherapy for underlying torticollis and
on occasion to the Infant Development Program for de-
velopmental delays
(d) Referral to a pediatric neurosurgeon for suspicion of
craniosynostosis
(e) Follow-up at the Plagiocephaly Clinic, usually within 4
to 6 weeks
Objectives
The objectives of this study were to determine the efficiency
of the clinic’s management of positional plagiocephaly and to
Childs Nerv Syst
investigate its ability to identify and refer patients with cranio-
synostosis to pediatric neurosurgeons for further assessment.
Methods
After institutional ethics approval was obtained, a retrospec-
tive chart review was conducted to identify all patients who
were independently assessed and managed at the
Plagiocephaly Clinic between 2008 and 2014. The following
variables were collected: patients’ age at first clinic assess-
ment, date of referral and date of first clinic assessment,
oblique diagonal difference (ODD) at first clinic assessment
(defined as the difference between the two diagonal measure-
ments of frontozygomaticus to opposite parietal eminence),
and recommended interventions. Since all infants in the prov-
ince of British Columbia (BC) who are diagnosed with cra-
niosynostosis are assessed at BCCH by a neurosurgeon, the
BCCH Pediatric Neurosurgery comprehensive database was
cross-referenced to identify any patients who were initially
misdiagnosed as having positional plagiocephaly by the
Plagiocephaly Clinic and later identified as having craniosyn-
ostosis by a pediatric neurosurgeon.
The data was reported as a descriptive analysis of the
following:
& Efficiency of the clinic as measured by average wait times
for assessment
& Characteristics of the patients seen by the clinic, including
the severity of plagiocephaly, based on their ODD and the
interventions that were recommended
& Accuracy of the clinic in identifying appropriate cases for
neurosurgical referral. Specifically, we determined the
percentage of patients referred to the BCCH Pediatric
Neurosurgery clinic for suspicion of craniosynostosis,
the percentage of referred patients for whom the neurosur-
geon requested a CT scan, and the percentage of referred
patients who required surgical correction of craniosynos-
tosis. The sensitivity and specificity of the clinic in refer-
ring craniosynostosis patients were calculated.
Results
A total of 1752 children were seen between 2008 and 2014 at
the BC Children’s Hospital Plagiocephaly Clinic by either the
occupational therapist or the general pediatrician. The charts
before 2008 were not readily available. The mean wait time
from referral to first assessment at the clinic was 41 days. The
average age at first assessment was 6.3 months and the per-
centages of mild, moderate, and severe positional
plagiocephaly were 47%, 33%, and 20 %, respectively. Most
patients were seen once (77%) or twice (19%) by the
Plagiocephaly Clinic, and only 4% required three or more
appointments.
Counseling about repositioning was provided to 66% of
patients. Cranial orthotic treatment was recommended in
34% of patients. Referrals were made to physiotherapy for
possible torticollis in 19% of patients.
Twenty-five patients (1.4 %) were referred by the
Plagiocephaly Clinic to the BC Children’s Pediatric
Neurosurgery clinic for suspicion of craniosynostosis, with a
mean wait time of 8 days. Of these patients, the pediatric
neurosurgeon ruled out craniosynostosis based on clinical
evaluation in 12 patients (50%), while 4 patients (17%) re-
ceived head imaging because the diagnosis was not clear clin-
ically. Eight patients (33%) were diagnosed with craniosynos-
tosis, 6 based on clinical evaluation, and the other 2 after head
imaging. The pediatric neurosurgeon suspected lambdoid cra-
niosynostosis in one additional referred patient and recom-
mended a CT scan, but the family refused and there was no
follow-up.
On the other hand, there were no patients who were diag-
nosed by the Plagiocephaly Clinic as having positional
plagiocephaly who subsequently required a craniosynostosis
operation. Therefore, the Plagiocephaly Clinic’s sensitivity
and specificity for referral of craniosynostosis patients to a
pediatric neurosurgeon were 100% and 99%, respectively.
Discussion
The BCCH Plagiocephaly Clinic is independently staffed by
an occupational therapist and a general pediatrician. In this
study, this innovative service delivery model was shown to
be both efficient and safe in managing patients referred by
family physicians and pediatricians for abnormal head shape,
with a presumed diagnosis of positional plagiocephaly. OTs
and general pediatricians are grounded in knowledge of infant
development and, with a short period of additional training, in
this case 15 min, are particularly well-suited to provide first-
line assessment and intervention of such infants.
The BCCH Plagiocephaly Clinic screens and manages 250
patients per year with a mean wait time of only 41 days,
compared with the typical wait time of approximately 3
months for non-urgent referrals to a pediatric neurosurgeon
at BCCH. This dramatic reduction in the burden to the
Pediatric Neurosurgery Clinic not only allows infants with
abnormal head shapes to be managed quickly and appropri-
ately but also improves access for children with other con-
cerns that require neurosurgical assessment.
The Plagiocephaly Clinic safely screened for craniosynos-
tosis, which requires different management strategies from
positional plagiocephaly, including surgical intervention. In
this study, the clinic referred only a minority of patients to a

pediatric neurosurgeon for assessment of craniosynostosis
(1.4%), with a very high sensitivity and specificity since all
patients with craniosynostosis and only few of non-
craniosynostosis patients were referred to neurosurgery clinic.
This is the first study in Canada to report the safety and
efficacy of independent allied health professionals in
assessing and managing plagiocephaly patients. Literature re-
view revealed one study in OR, USA, that discussed pediatric
nurse practitioners as the initial evaluators of children with
plagiocephaly [25], which concluded that this was safe and
effective with a high sensitivity (100%) but relatively low
specificity (21%). Furthermore, the pediatric nurse practi-
tioners reported enhanced professional satisfaction and inte-
gration into a patient-centered, disease-focused subspecialty
team.
However, there are important differences between the
BCCH Plagiocephaly Clinic and the one in OR. First, the
nurse practitioners had 1 year of training, while the OT and
general pediatrician at BCCH had only a 15-min additional
training session with comparable safety results. Second, the
nurse practitioners had the ability to order CT imaging for
patients. A total of 45% of patients received imaging in
Oregon and only 9.8% were diagnosed with craniosynostosis,
which raises the concern about overuse of imaging. In the
BCCH Plagiocephaly Clinic, neither the OT nor general pedi-
atrician ordered CT scans; instead, they referred atypical
cases, suspected as having craniosynostosis, to a pediatric
neurosurgeon, which resulted in a small number of patients
requiring imaging. Finally, referral patterns between the two
centers differed greatly: in OR, 48% of patients were referred
by a nurse practitioner to a pediatric neurosurgeon for further
assessment, while only 1.4% of patients seen at the BCCH
Plagiocephaly Clinic were referred.
Although this is a large patient-based study with adequate
sample size to detect any missed cases of craniosynostosis,
multiple limitations must be considered. The data was collect-
ed retrospectively, which raises the concern for data complete-
ness and correctness. Many patients were seen only once in
the Plagiocephaly Clinic with a lack of long-term follow-up.
However, the list of patients seen at the Plagiocephaly Clinic
was cross-referenced with the comprehensive BCCH prospec-
tive neurosurgical database, which contains all children who
have been seen for consultation or have received surgical in-
tervention by a pediatric neurosurgeon in the province of BC.
If Plagiocephaly Clinic patients were subsequently seen by
pediatric neurosurgeons in other provinces or countries, they
would not have been captured in this study, but the probability
of that occurring is considered very low.
Given the study’s sample size and the comprehensiveness
of the neurosurgical database, these limitations are unlikely to
invalidate the results of this study. In future studies, other
potential benefits of the Plagiocephaly Clinic could be ex-
plored, including a financial analysis of this model’s costs
Childs Nerv Syst
compared with the traditional model of direct referral to pedi-
atric neurosurgery.
For other centers considering this model of care, it should
be noted that while our Plagiocephly Clinic is run indepen-
dently by an OT and pediatrician, there are built in protections.
Firstly, while the additional training to screen for synostosis
was brief, both these health care professionals had previous
familiarity seeing infants with plagiocephaly and screening for
developmental delays. In addition, the clinic is supported by
the Division of Neurosurgery, with consult readily available.
Secondly, both our clinicians are regulated professionals and
have no conflict of interest for provision of orthotic treatment.
Other regulated health care professionals with similar training
and scope of practice may also be appropriate, such as phys-
iotherapists and nurse practitioners. Finally, this retrospective
review included up until 2014 and prior to further RCT and
prognostic evidence questioning the long-term benefit of or-
thotic treatment [13, 15]. Anecdotally, our clinic has signifi-
cantly lowered the percentage of children referred for orthotic
treatment since this time.
Conclusion
The BCCH Plagiocephaly Clinic is efficient and safe for the
initial evaluation and treatment of patients with presumed po-
sitional plagiocephaly. The clinic’s model, in which allied
health professionals are trained to see patients independently,
could be considered in other medical centers because it de-
creases wait times, appropriately manages patients with posi-
tional plagiocephaly, and screens for craniosynostosis with
high sensitivity and specificity.
Acknowledgments The authors would like to acknowledge Alexander
Cheong for his contributions during the drafting of the manuscript.
Compliance with ethical standards
Conflict of interest On behalf of all authors, the corresponding author
states that there is no conflict of interest.
References
1. Bialocerkowski AE, Vladusic SL, Wei Ng C (2008) Prevalence,
risk factors, and natural history of positional plagiocephaly: a sys-
tematic review. Developmental medicine and child neurology 50:
577–586
2. Joganic JL, Lynch JM, Littlefield TR, Verrelli BC (2009) Risk
factors associated with deformational plagiocephaly. Pediatrics
124:e1126–e1133
3. van Vlimmeren LA, van der Graaf Y, Boere-Boonekamp MM,
L’Hoir MP, Helders PJ, Engelbert RH (2007) Risk factors for de-
formational plagiocephaly at birth and at 7 weeks of age: a prospec-
tive cohort study. Pediatrics 119:e408–e418
Childs Nerv Syst
4. Agrawal D, Steinbok P, Cochrane DD (2007) Significance of beat-
en copper appearance on skull radiographs in children with isolated
sagittal synostosis. Child’s nervous system : ChNS : official journal
of the International Society for Pediatric Neurosurgery 23:1467–
1470
5. Kapp-Simon KA, Speltz ML, Cunningham ML, Patel PK, Tomita
T (2007) Neurodevelopment of children with single suture cranio-
synostosis: a review. Child’s nervous system : ChNS : official jour-
nal of the International Society for Pediatric Neurosurgery 23:269–
281
6. Renier D, Sainte-Rose C, Marchac D, Hirsch JF (1982) Intracranial
pressure in craniostenosis. Journal of neurosurgery 57:370–377
7. Tamburrini G, Caldarelli M, Massimi L, Santini P, Di Rocco C
(2005) Intracranial pressure monitoring in children with single su-
ture and complex craniosynostosis: a review. Child’s nervous sys-
tem : ChNS : official journal of the International Society for
Pediatric Neurosurgery 21:913–921
8. Agrawal D, Steinbok P, Cochrane DD (2006) Diagnosis of isolated
sagittal synostosis: are radiographic studies necessary? Child’s ner-
vous system : ChNS : official journal of the International Society for
Pediatric Neurosurgery 22:375–378
9. Cho MJ, Borchert LL, Kane AA (2017) Diagnostic yield of routine
skull radiographs in infants with deformational plagiocephaly. The
Cleft palate-craniofacial journal : official publication of the
American Cleft Palate-Craniofacial Association 54:497–501
10. Aarnivala H, Vuollo V, Harila V, Heikkinen T, Pirttiniemi P,
Valkama AM (2015) Preventing deformational plagiocephaly
through parent guidance: a randomized, controlled trial. European
journal of pediatrics 174:1197–1208
11. Hutchison BL, Stewart AW, Mitchell EA (2011) Deformational
plagiocephaly: a follow-up of head shape, parental concern and
neurodevelopment at ages 3 and 4 years. Archives of disease in
childhood 96:85–90
12. van Vlimmeren LA, van der Graaf Y, Boere-Boonekamp MM,
L’Hoir MP, Helders PJ, Engelbert RH (2008) Effect of pediatric
physical therapy on deformational plagiocephaly in children with
positional preference: a randomized controlled trial. Archives of
pediatrics & adolescent medicine 162:712–718
13. Collett BR, Leroux BG, Wallace ER, Gallagher E, Shao J, Speltz
ML (2018) Head shape at age 36 months among children with and
without a history of positional skull deformation. Journal of neuro-
surgery Pediatrics 21:204–213
14. Lin RS, Stevens PM, Wininger M, Castiglione CL (2016) Orthotic
management of deformational plagiocephaly: consensus clinical
standards of care. The Cleft palate-craniofacial journal : official
publication of the American Cleft Palate-Craniofacial Association
53:394–403
15. van Wijk RM, van Vlimmeren LA, Groothuis-Oudshoorn CG, Van
der Ploeg CP, Ijzerman MJ, Boere-Boonekamp MM (2014) Helmet
therapy in infants with positional skull deformation: randomised
controlled trial. Bmj 348:g2741
16. Weissler EH, Sherif RD, Taub PJ (2016) An Evidence-Based
Approach to Nonsynostotic Plagiocephaly. Plastic and reconstruc-
tive surgery 138:682e–689e
17. Branch LG, Kesty K, Krebs E, Wright L, Leger S, David LR (2015)
Deformational plagiocephaly and craniosynostosis: trends in diag-
nosis and treatment after the “back to sleep” campaign. The Journal
of craniofacial surgery 26:147–150
18. Mawji A, Vollman AR, Hatfield J, McNeil DA, Sauve R (2013)
The incidence of positional plagiocephaly: a cohort study.
Pediatrics 132:298–304
19. Laughlin J, Luerssen TG, Dias MS, Committee on P, Ambulatory
Medicine SoNS (2011) Prevention and management of positional
skull deformities in infants. Pediatrics 128:1236–1241
20. Martinez-Lage JF, Arraez Manrique C, Ruiz-Espejo AM, Lopez-
Guerrero AL, Almagro MJ, Galarza M (2012) Positional cranial
deformations: a clinical-epidemiological study. Anales de pediatria
77:176–183
21. Mildred J, Beard K, Dallwitz A, Unwin J (1995) Play position is
influenced by knowledge of SIDS sleep position recommendations.
Journal of paediatrics and child health 31:499–502
22. Hutchison BL, Hutchison LA, Thompson JM, Mitchell EA (2004)
Plagiocephaly and brachycephaly in the first two years of life: a
prospective cohort study. Pediatrics 114:970–980
23. Aarnivala HE, Valkama AM, Pirttiniemi PM (2014) Cranial shape,
size and cervical motion in normal newborns. Early human devel-
opment 90:425–430
24. Peitsch WK, Keefer CH, LaBrie RA, Mulliken JB (2002) Incidence
of cranial asymmetry in healthy newborns. Pediatrics 110:e72
25. Kuang AA, Bergquist C, Crupi L, Oliverio M, Selden NR (2013)
Effectiveness and safety of independent pediatric nurse practi-
tioners in evaluating plagiocephaly. Plastic and reconstructive sur-
gery 132:414–418
Publisher’s note Springer Nature remains neutral with regard to jurisdic-
tional claims in published maps and institutional affiliations.