2021/5/3 A pediatric epidemic: Deformational plagiocephaly/brachycephaly and congenital muscular torticollis

A pediatric epidemic: Deformational

plagiocephaly/brachycephaly and congenital
muscular torticollis
February 2, 2019
Regina Fenton, CRNP , Susan A Gaetani, PT, DPT
Contemporary PEDS Journal, Vol 36 No 2, Volume 36, Issue 2

Pediatric healthcare providers are on the front lines to provide early identification and
treatment of plagiocephaly/brachycephaly and torticollis for those infants spending more
time supine/reclined and less time prone. Here’s why early intervention is so important.

A pediatric epidemic is sweeping the country. The incidence

of infant deformational plagiocephaly and brachycephaly
(DPB) and congenital muscular torticollis (CMT) has been on
an upward spiral since 1992 when the American Academy of
Pediatrics (AAP) instituted the “Back to Sleep” campaign.1
Infants are spending more time supine and in reclined
positions day and night and less time prone than in the
past.2 We postulate that the widespread increase in DPB and Algorithm for PCPs
CMT is multifactorial, including frequent use of and/or
sleeping in reclined positioners and chairs such as bouncy
seats, reclined rockers, swings, and car seats, and
Early identification of
dramatically decreased tummy time. DPB/CMT

Clinics and pediatrician o ces have become inundated with

patients exhibiting DPB and CMT, leading to a substantial
escalation in costs to the healthcare system. Other
repercussions from these diagnoses are an increased need
for physical therapy (PT) services and use of helmet therapy
(HT), which place additional stress on a family’s time and
nancial resources. Most community- and government- Figures 1-3
funded programs (Birth-to-3, early intervention) are strained
to accommodate expanding demand for these services.

The aim of this article is to heighten awareness of this

epidemic. Pediatric healthcare providers are on the front Figure 4A, 4B, 4C
lines to intervene early in its evolution, allowing them to
identify, prevent, and/or treat DPB and CMT with
conservative measures. Hopefully, these measures will
reverse the process and decrease or eliminate associated
exorbitant healthcare costs.

DPB and CMT

Deformational plagiocephaly/brachycephaly occurs from

prolonged pressure on the baby’s skull in utero or soon after
birth, causing an asymmetric (plagiocephaly) and/or wide
(brachycephalic) head shape. The skull is soft and malleable
until ossi cation begins at age 5 to 6 months. When a baby
develops a preferred position, the skull will atten in that
area. If the misshapen area is unilateral, the ear, forehead,
and cheek will shift anteriorly and impact cosmesis. If the

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misshapen area is bilateral, the back of the head will widen Torticollis: Other associated
and may look tall or turricephalic. Incidence of DPB ranges problems
from 18% to 19.7%.3

Congenital muscular torticollis occurs when the

sternocleidomastoid (SCM) muscle becomes shortened or
restricted unilaterally. The head then turns to the opposite
side and/or tilts downward to the same side, resulting in a
preferred head position. It becomes di cult for the infant to
independently alter head position, and prolonged pressure
on the same area occurs when the infant is in a reclined
position or sleeping. Also, CMT may develop prenatally due
to restricted intrauterine positioning, during delivery, or
because of DPB or other external forces. This strains the
Figure 5A and 5B
SCM and surrounding neck musculature causing cervical
muscle imbalance and positional preference. The 2
diagnoses usually occur together, creating a synergistic
effect.4 Additionally, DPB is strongly associated with CMT-as
high as 70% to 95%.3

In the United States, CMT is the third-most common

orthopedic diagnosis in infants. Like DPB, its incidence has
increased, with a reported range of 0.4% to 1.9% in earlier
studies.1,5-9 A rate as high as 16% was reported by 2008.10
Also, CMT has been associated with comorbidities including
DPB, facial asymmetries, mandibular asymmetry (MA),
developmental hip dysplasia, and gross motor skill
asymmetries. Children diagnosed with CMT are treated with Time Time: Effective Positions
skilled PT services to address weakness, range-of-motion
limitations, postural de cits, and altered gross motor skill
acquisition. A course of PT successfully resolves 90% to Aggressive repositioning
99% of CMT. Surgical intervention (eg, SCM release) is rarely
necessary.1,11

Congenital muscular torticollis has an association with MA that can lead to long-term facial
asymmetry.1,12 Unilateral ramal height growth restriction, causing jaw asymmetry, results
from CMT due to abnormal muscle forces. Mandibular asymmetry can be identi ed by
approximating the mandible to the maxilla. The mandible will cant upward on the side of the
head tilt. Physical therapy for the torticollis will address the MA, which is important because
MA can affect feeding, especially the ability to achieve latch and adequate suction for
breastfeeding.13 Addressing MA early means a greater potential for improvement and
resolution. Craniofacial asymmetries, including MA, can become more severe with age when
delay or if CMT remains untreated.14
treatment of CMT is delayed

Identifying the problem

Most parents notice the attening or misshaping of their infant’s head shape between age 1
and 2 months. Parents and primary care physicians (PCPs) do not always recognize CMT
because presentation may be subtle. Parents tell us they mention their concern about
abnormal head shape and/or positional preference to their PCP but are told it will
spontaneously improve once the infant is rolling over and sitting upright. They are
discouraged when this does not happen. Although many PCPs believe what they are telling
concerned parents about spontaneous improvement, this is typically not the case unless
interventions are initiated much earlier in infancy.

In the United States in 2017, 3.8 million babies were born. As noted earlier, incidence of DPB
ranges from 18% to 19.7%-about 720,000 infants per year born with DPB.3 About 100 US
pediatric plastic surgery/cleft-craniofacial centers each see nearly 100 patients with these
diagnoses per month. This does not account for other providers including neurosurgeons or
pediatricians. Only about 100,000 of 720,000 infants per year are currently being identi ed
and treated, leaving 86% (620,000) unidenti ed and untreated. Given long-term, often
irreversible, sequelae, this is a serious problem.

Our center’s experience

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At our institution, the University of Pittsburgh Medical Center (UPMC) Children’s Hospital of
Pittsburgh, Pennsylvania, the cleft-craniofacial center is embedded in the pediatric plastic
surgery department. With more than 100 new patients referred to us monthly, most of whom
having both DPB and CMT, we developed a multidisciplinary clinic in 2010. Our
comprehensive team evaluation and treatment approach includes a nurse practitioner and a
physical therapist. With this approach, we are able to institute PT and aggressive
repositioning (AR) management at the initial appointment, beginning these conservative
measures as soon as possible. Combining these services saves time and money for parents
and/or guardians by eliminating the need to schedule a separate PT appointment.

Patients receive a wealth of information during a medical appointment, of which about 80%
is not retained once they leave the o ce.15 To reinforce our recommendations and
instruction, we have developed printed patient-education materials to increase
understanding and compliance. Handouts include information sheets on DPB and AR
techniques as well as brochures about tummy time and torticollis that describe home
exercises for CMT.

We also provide community outreach to our regional PCPs and pediatric therapists. Our
purpose is to increase awareness of these diagnoses and emphasize the small but critical
time frame available to institute conservative measures to treat DPB.

Diagnosis and evaluation

Diagnosis of DPB is determined by physical exam. The cranial exam is performed by having
the parent/guardian hold the infant in his/her lap while the nurse practitioner examines the
baby from the vertex view (Figure 1). This exam ascertains whether the DPB is unilateral or
bilateral. Unilateral DPB most frequently manifests in a parallelogram shape of the head
(Figure 2). The attened side of the head displaces the ear forward anteriorly, causing
forehead bossing and fullness of the cheek on the affected side. The orbital opening may be
larger on the affected side. Bilateral DPB results in signi cant brachycephaly (Figure 3).
Facial features are not as affected in brachycephalic patients unless both brachycephaly
and asymmetry are demonstrated.

When assessing the cranial vault, a hand caliper is used to measure the cranial index (CI),
also referred to as the cephalic ratio, de ned as the width divided by the length. The oblique
diagonal difference (ODD) is a measurement of the asymmetry of the cranial vault. The CI
and ODD provide objective guidelines with which to determine DPB severity (Figure 4).
Criteria for cranial vault measurements have not been standardized, but an ODD equal to or
greater than 12 mm (and/or con dence index [CI] ≥1.0) has been used to denote DPB as
severe. These measurements guide treatment decision-making; eg, mild DPB is treated
conservatively with AR and PT.

If the baby is aged 4.5 to 5 months or older and has moderate or severe cranial vault
measurements, the parent/guardian is offered HT as a choice. The infant must show
adequate head and neck control. We verify this developmental achievement by performing a
pull-to-sit test to ensure a strong chin tuck is present and there is no head lag (Figure 5). If
head lag exists, we recommend increasing tummy time to achieve improved head and neck
control and a return visit once adequate head and neck control is achieved. Helmets weigh
about 8 ounces, which is a signi cant weight to place on an infant’s head. Infant safety must
be ensured with HT as poor head and neck control combined with the weight of a helmet
could potentially compromise respiratory status.

Differential diagnosis

When evaluating these patients, differential diagnoses including craniosynostosis,

macrocephaly, hemifacial microsomia, and hydrocephalus must be considered. The
occipital frontal circumference is obtained to evaluate for macrocephaly. If there are
concerns about head size, we refer to neurosurgery for further evaluation. Cranial sutures
are evaluated via palpation for any indication of suture ridging, which can be suggestive of
craniosynostosis (fusion or premature closure of skull sutures). If cranial suture ridging is
identi ed and ndings are consistent with craniosynostosis, a 3-dimensional computed
tomography (3D CT) scan is indicated and HT deferred until it is completed.

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Skull x-rays are rarely indicated or helpful. If the 3D CT scan shows craniosynostosis, the
patient is referred to a craniofacial surgeon. If the scan does not indicate craniosynostosis,
HT can be considered. Some asymmetric facial features observed in children with mild
hemifacial microsomia may also be seen in children with DPB and CMT. Children with
hemifacial microsomia, however, typically do not present with DPB and/or CMT.

Role of the physical therapist

The physical therapist evaluates the patient’s neck, spine, hips, feet, and provides gross
motor skill screening. If the infant has CMT, parents and/or guardians are educated about it,
taught exercises to begin immediately, and counseled on initiating PT services via
outpatient or early intervention (Birth-to-3). In our state, parents/guardians often opt for
early intervention because the state-funded programs do not require insurance and provide
the convenience of a physical therapist coming to the home, daycare, or sitter’s home. Such
services can take up to a month to initiate, so exercises must start right away. Frequency of
PT is weekly or every other week, becoming less frequent as the infant improves. Standard
of care for CMT is to continue with PT until the child is walking independently to ensure
gross motor milestones are achieved and performed symmetrically.11

Up to 99% of CMT resolves with PT and less than 0% to 1% requires surgical intervention.11
Often CMT manifests with soft tissue restriction of the neck and shoulders, including
bromatosis colli within the SCM in 10% to 50% of cases.1 Families are taught massage for
the soft tissue restrictions, which can take months to resolve. Also, a 10% to 14.9%
correlation of CMT with developmental hip dysplasia has been documented.1,16,17 The
physical therapist undertakes a clinical hip evaluation, and if there are any concerns, the
patient is referred to a pediatric healthcare provider or to orthopedics.

Critical importance of tummy time

Initiating awake prone time immediately is crucial in the newborn period. Although parents
are well educated about the Back to Sleep campaign to prevent sudden infant death
syndrome, they rarely receive su cient information on the bene ts and techniques of
tummy time. Our brochure on tummy time reviews techniques for families to use to achieve
the goal of 81 minutes by age 4 months.2

Tummy time strengthens the infant’s neck and core and relieves pressure from the head. It
is inexpensive, easy to do, and does not require additional products or have associated
costs. It would be most bene cial if tummy time were reviewed by the pediatrician or
healthcare personnel within the practice during the rst newborn appointments. The slogan
“Back to sleep, tummy to play” establishes a simple but important message.

Impact of aggressive repositioning

If patients are referred early, between age 0 and 4 months, we initiate the conservative
measures of AR and PT. Such techniques are effective then because the skull is soft and
malleable until age 5 to 6 months. We strongly support the AAP recommendations of
sleeping on a at, rm surface. Many families have their babies sleeping in reclined chairs,
which we believe exacerbates DPB and CMT. In an effort to minimize pressure on the
misshaped side of the head, we teach families to use AR. We use a receiving blanket rolled
up like a log and tucked behind the affected side of the head, shoulder, waist, and hip when
the baby is resting, especially in reclined chairs (eg, bouncy, Fisher Price Rock ‘n Play, or
swing chairs). The goal is to minimize reclined positioning and increase upright seating
when developmentally appropriate.

Upright chairs for emerging sitters (eg, Bumbo, Fisher Price Sit-Me-Up, Summer Infant,
BebePod) are recommended at age 3 to 4 months. These chairs provide necessary back
support but allow pressure to be removed from the head. They should be introduced in short
intervals, increased as the baby adjusts, and placed on the oor, never on a table or counter
due to concern over fall risk. Parents are encouraged to use front carriers in their daily
activities to remove pressure from the baby’s head.

Feeding techniques for both bottle-feeding and breastfeeding are provided to support the
head and neck, reducing pressure on the affected side of the skull. It is important to reduce
laying the baby’s affected side of the head on an arm or items like a pillow. Visual
stimulation encourages the baby to look to the opposite side from the DPB.

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We use AAP guidelines and state trooper guidelines for car-seat positioning.18 These
guidelines require the infant be safely buckled into the car seat and the blanket roll tucked
behind the affected side of the head, shoulder, and hip outside of straps and buckles. The
family is taught to take the infant out of the reclined car seat upon reaching their destination
to prevent further pressure on the affected side of the head. This can be done by holding the
baby, using a front carrier, or, when developmentally appropriate, the stroller. We offer a
prescription for AR if the baby is enrolled in daycare.

Cranial remolding helmet therapy

Patients return for further evaluation between age 4.5 and 5 months. If conservative
techniques have been effective in improving or halting progression of DPB and its severity
does not meet criteria for HT, we recommend continuing AR and PT. If between 4.5 and 5
months infants still show signi cant DPB and meet criteria, we offer HT and many parents
agree to it. Again, HT has proved most effective when the skull is still malleable, brain
growth is robust, and when initiated prior to the ossi cation process.19 We inform families
that DPB is a functional cosmetic issue because patients need to t into safety helmets
properly when they begin to ride bikes or play helmeted sports. Risk of concussion should
not be increased by an ill- tting helmet due to an abnormal head shape.

Although highly effective, HT can be time consuming and stigmatizing. Often, mothers tell
us they feel they have done something to cause this problem. Many cultures are not open to
HT. The potential adverse effects of HT include skin issues; ie, rashes, pressure areas,
wounds, contact dermatitis, and exacerbation of eczema, seborrhea, or cradle cap. Infants
also can become overheated when wearing helmets. Loss of work due to follow-up
appointments for adjustments can impact the family. Finally, HT can be very expensive and
insurance coverage may be lacking.

Of note, the AAP clinical report from 2011 found no evidence that molding helmets work any
better than repositioning for mild or moderate skull deformity.20 Based on studies available
then, the best use of helmets for severe deformity is at age 4 to 12 months because of the
greater malleability and rapid brain growth. Since 2011, however, newer, larger studies have
been completed on the e cacy of HT.

In 2014, a prospective, nonrandomized study recommended treating mild plagiocephaly

with repositioning and that HT be the treatment of choice for moderate-to-severe
plagiocephaly.21 Another study of 4378 patients found that both conservative treatment and
HT were effective.22 Recommendations included repositioning rst and HT if repositioning
was not effective, or if the baby was older or the condition more severe. A 2015 long-term
outcome study comparing those who used helmets versus repositioning found HT provided
greater improvement in skull shape than the conservative measure.23 In contrast to other
recent ndings, a 2016 study found clear improvement in nonsynostotic head deformity
treated with a molding helmet and no clear evidence of improvement of absolute
measurements in untreated cranial deformity within a 5-year follow-up.24

Although recent review/guidelines from the Congress of Neurological Surgeons (CNS) on

HT for patients with positional plagiocephaly indicate AR and PT are important, the report
stresses that HT is more effective in reshaping the plagiocephaly.25 It concludes that a body
of nonrandomized evidence has shown “more signi cant and faster improvement of cranial
shape in infants with positional plagiocephaly treated with a helmet in comparison with
conservative therapy, especially if the deformity is severe, provided that helmet therapy is
applied during the appropriate period of infancy.”

We propose, however, that AR and PT initiated early enough have the potential to be as
effective as HT in addressing DPB. Patients are rarely referred to us in this early critical
timeframe, but when they are, the conservative measures of AR and PT halt or reverse DPB,
resulting in substantial improvement and even negating the need for HT. Although it has not
been our experience, concerns exist about the overprescribing of HT, but that issue is
beyond the scope of this article’s focus.

The epidemic of DPB and CMT has caused a signi cant nancial burden on the healthcare
system, especially when HT is used. As the majority of infants are referred too late to
institute conservative measures, HT becomes the only option, one that we estimate costs
$3.6 million at our center for approximately 900 patients per year.

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The United States has over 100 craniofacial centers, and certainly speci c costs attributed
to this problem vary among them. Nevertheless, referencing our costs for HT as well as
plastic surgery consults and PT evaluations and sessions, and multiplying it by 100 centers
across the country, the rough gross estimate for costs nationwide quickly reaches more
than $1 billion. As well, this estimate does not include costs for patients treated by
neurosurgery centers or other providers, missed work, or transportation.

Prevention

Few medical issues occur with this prevalence in otherwise healthy infants, and little
attention has been paid to prevention or early treatment in light of the increased numbers of
infants with this diagnosis since 1992. Research supporting effective prevention strategies
is scant. We recently completed a pilot study approved by the Institutional Review Board
that demonstrated support of early referral resulting in less-frequent HT. A Finnish study
also has shown that initiating preventive education in the maternity ward from the time
infants are born provides signi cant reduction in the number of infants who develop
deformational plagiocephaly or require HT.4

Conclusion

Pediatric healthcare providers are in the best position to identify and manage DPB and CMT.
Evaluation of the infant’s head shape and range of motion of the neck should be
incorporated into the 1- and 2-month well-child appointments. If any concerns are noted, AR
and referral to PT should be initiated immediately.

Lack of intervention or suggesting it will resolve once the baby is rolling and sitting is
usually a fallacy. Conservative measures are most effective when the skull is still malleable
prior to onset of ossi cation. If no improvement is observed by the 4-month well-child
appointment, referral to a specialist is recommended. Early identi cation and treatment are
critical. They can dramatically improve the patient’s course and provide the momentum to
begin to minimize, and hopefully reverse, this epidemic.

References:
1. Karmel-Ross K. Congenital muscular torticollis. In: Campbell SK, Palisano RJ, Orlin MN,
eds. Physical Therapy for Children. 4th ed. St. Louis, MO: Elsevier Saunders; 2012:292-312.

2. Dudek-Shriber L, Zelazny S. The effects of prone positioning on the quality and acquisition
of developmental milestones in four-month-old infants. Pediatr Phys Ther. 2007;19(1):48-
55.

3. Rogers GF. Deformational plagiocephaly, brachycephaly, and scaphocephaly. Part 1:

terminology, diagnosis, and etiopathogenesis. J Craniofac Surg. 2011;22(1):9-16.

4. Aarnivala H, Vuollo V, Harila V, Heikkinen T, Pirttiniemi P, Valkama AM. Preventing

deformational plagiocephaly through parent guidance: a randomized, controlled trial. Eur J
Pediatr. 2015;174(9):1197-1208.

5. Cheng JC, Au AW. Infantile torticollis: a review of 624 cases. J Pediatr Orthop.
1994;14(6):802-808.

6. Cheng JC, Tang SP, Chen TM. Sternocleidomastoid pseudotumor and congenital
muscular torticollis in infants: a prospective study of 510 cases. J Pediatr. 1999;134(6):712-
716.

7. Cheng JC, Wong MW, Tang SP, Chen TM, Shum SL, Wong EM. Clinical determinants of the
outcome of manual stretching in the treatment of congenital muscular torticollis in infants.
A prospective study of eight hundred and twenty-one cases. J Bone Joint Surg Am. 2001;83-
A(5):679-687.

8. Do TT. Congenital muscular torticollis: current concepts and review of treatment. Curr
Opin Pediatr. 2006;18(1):26-29.

9. Tatli B, Aydinli N, Caliskan M, Ozmen M, Bilir F, Acar G. Congenital muscular torticollis:

evaluation and classi cation. Pediatr Neurol. 2006;34(1):41-44.

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10. Stellwagen L, Hubbard E, Chambers C, Jones KL. Torticollis, facial asymmetry and
plagiocephaly in normal newborns. Arch Dis Child. 2008;93(10):827-831.

11. Kaplan S, Coulter C, Sargent B. Physical therapy management of congenital muscular

torticollis: a 2018 evidence-based clinical practice guideline from the APTA Academy of
Pediatric Physical Therapy. Pediatr Phys Ther. 2018;30(4):240-290.

12. Kawamoto HK, Kim SS, Jarrahy R, Bradley JP. Differential diagnosis of the idiopathic
laterally deviated mandible. Plast Reconstr Surg. 2009;124(5):1599-1609.

13. Wall V, Glass R. Mandibular asymmetry and breastfeeding problems: experience from 11
cases. J Hum Lact. 2006;22(3):328-334.

14. Jeong KY, Min KJ, Woo J, Yim SY. Craniofacial asymmetry in adults with neglected
congenital muscular torticollis. Ann Rehabil Med. 2015;39(3):440-450.

15. Bass PF. 3 steps to boost health literacy. Contemp Pediatr. 2018;35(1):13-14.

16. Jackson JC, Runge MM, Nye NS. Common questions about developmental dysplasia of
the hip. Am Fam Physician. 2014;90(12):843-850.

17. Kim SN, Shin YB, Kim W, et al. Screening for the coexistence of congenital muscular
torticollis and developmental dysplasia of hip. Ann Rehabil Med. 2011;35(4):485-490.

18. American Academy of Pediatrics. Car seats: information for families.

HealthyChildren.org website. Available at: https://www.healthychildren.org/English/safety-
prevention/on-the-go/Pages/Car-Safety-Seats-Information-for-Families.aspx. Updated
August 30, 2018. Accessed January 23, 2019.

19. Kluba S, Kraut W, Reinert S, Krimmel M. What is the optimal time to start helmet therapy
in positional plagiocephaly? Plast Reconstr Surg. 2011;128(2):492-498.

20. Laughlin J, Luerssen TG, Dias MS; Committee on Practice and Ambulatory Medicine,
Section on Neurological Surgery. Prevention and management of positional skull
deformities in infants. Pediatrics. 2011;128(6):1236-1241. Erratum in: Pediatrics.
2012;129(3):595.

21. Kluba S, Kraut W, Calgeer B, Reinert S, Krimmel M. Treatment of positional

plagiocephaly-helmet or no helmet? J Craniomaxillofac Surg. 2014;42(5):683-688.

22. Steinberg JP, Rawlani R, Humphries LS, Rawlani V, Vicari FA. Effectiveness of
conservative therapy and helmet therapy for positional cranial deformation. Plast Reconstr
Surg. 2015;135(3):833-842.

23. Naidoo SD, Skolnick GB, Patel KB, Woo AS, Cheng AL. Long-term outcomes in treatment
of deformational plagiocephaly and brachycephaly using helmet therapy and repositioning:
a longitudinal cohort study. Childs Nerv Syst. 2015;31(9):1547-1552.

24. Wilbrand JF, Lautenbacher N, Pons-Kühnermann J, et al. Treated versus untreated

positional head deformity. J Craniofac Surg. 2016;27(1):13-18.

25. Flannery AM, Tamber MS, Mazzola C, et al. Congress of Neurological Surgeons
systematic review and evidence-based guidelines for the management of patients with
positional plagiocephaly: executive summary. Neurosurgery. 2016;79(5):623-624.

Download Issue : Vol 36 No 2

Developmental outcomes of positional

plagiocephaly
February 2, 2019
Rachael Zimlich, RN, BSN
Contemporary PEDS Journal, Vol 36 No 2,

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A new study urges pediatricians to screen for cognitive challenges as children with PPB
age.

Flattening of the skull on the back or side of an infant’s head-also known as positional
plagiocephaly and/or brachycephaly (PPB)-is a common problem seen in pediatric practice.
Although attened skulls in infancy, often considered a benign issue, can be corrected, a
new study investigates the long-term cognitive outcomes of more severe malformations.

In a new study published in Pediatrics, researchers evaluated the long-term cognitive and
academic impact of PPB.1 In a separate study, published in the European Journal of
Pediatrics,2 37.8% of infants had some degree of plagiocephaly by age 8 to 12 weeks, and
another 15% presented with brachycephaly. Plagiocephaly is de ned as a attened head on
one side resulting in asymmetry, possibly accompanied by misaligned ears. In
brachycephaly, the back of the head becomes attened, resulting in a widened head and
occasional bulging of the forehead. These conditions can be caused by positioning in the
womb or after birth, with a spike in cases noted after the American Academy of Pediatrics
issued its recommendation that infants sleep at on their backs to prevent sudden infant
death syndrome (SIDS).

Not so benign?

Whereas these common conditions have long been thought to be a benign cosmetic issue,
the research team that developed the new Pediatrics study notes that associations have
been made between PPB and neurodevelopmental de cits.1

To test these associations further, a research team evaluated 336 children with a mean age
of 9 years who had had PPB in infancy. Researchers found that children with moderate to
severe PPB were more likely to have required some form of developmental intervention than
their peers, with 66% of the children who had PPB in infancy requiring intervention
compared with 21% of their peers. Twenty-eight percent of the children in the PPB cohort
had had mild PPB as infants and 72% had moderate to severe PPB. As for treatment during
infancy, 34% had worn orthotic helmets to treat their PPB, and 45% had torticollis-a twisting
of the neck muscles caused by positioning of the head.

Although mean cognitive and academic scores for the PPB cohort were generally within
average range, the research team notes that children with PPB scored lower on most
cognitive and achievement tests performed over the course of the study, with children who
had moderate to severe PPB scoring lower than those with mild cases.

“Children who had moderate to severe PPB in infancy had persistently lower scores on tests
of cognition and, to a lesser extent, academic achievement than children without PPB
(controls),” says lead author Brent Collett, PHD, an associate professor in the Department of
Psychiatry and Behavioral Sciences at the University of Washington School of Medicine,
Seattle. “Children who had mild PPB as infants did not differ from controls.”

The researchers stop short of stating that PPB has a causal relationship to developmental
problems but note that PPB might rather be used as a marker for developmental
vulnerability, and add that treating skull deformations may be less important than tracking
developmental progress and offering early intervention when needed.

Ongoing monitoring and referral

Collett says it’s important for pediatricians to monitor patients with PPB, even after the
malformation is treated.

“For infants with more noticeable (moderate to severe) deformation, pediatricians should
provide developmental assessment and monitoring or refer infants to a developmental
specialist,” Collett says. “For infants with mild deformation, pediatricians could use the
results of our study to reassure parents who often worry about developmental effects.”

Collett says he hopes that the study will help guide pediatricians in the management of the
long-term effects of PPB.

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“We hope that our results will guide efforts to identify babies with
plagiocephaly/brachycephaly who would bene t from developmental
assessment/monitoring and early intervention, potentially offsetting case-control
differences like those observed in our study,” he says. “We also anticipate that our ndings
will prompt further research into strategies and tools that pediatricians could use to
evaluate the severity of deformation in their practice, which would guide referrals to
craniofacial centers, early interventionists, and other providers.”

References:
1. Collett BR. Wallace ER, Kartin D, Cunningham ML, Speltz ML. Cognitive outcomes and
positional plagiocephaly. Pediatrics. January 11, 2019. Epub ahead of print. Available at:
http://pediatrics.aappublications.org/content/early/2019/01/09/peds.2018-2373. Accessed
January 25, 2019.

2. Ballaradini E, Sisti M, Basaglia N, et al. Prevalence and characteristics of positional

plagiocephaly in healthy full-term infants at 8-12 weeks of life. Eur J Pediatr.
2018;177(10):1547-1554. Available at: https://link.springer.com/article/10.1007%2Fs00431-
018-3212-0. Accessed January 25, 2019.

Download Issue : Vol 36 No 2

Pediatric oral health: Fluoride use

recommendations
February 1, 2019
Michelle Dalal, MD , Melinda Clark, MD , Rocio B Quiñonez, DMD, MS, MPH
Contemporary PEDS Journal, Vol 36 No 2,

The second part of this article on integrating oral health into primary pediatric care
discusses the important role of fluoride and fluoride varnish application for preventing dental
caries in children.

Dental caries (cavities) continues to be the most chronic

disease of childhood.1 Although dental caries is
multifactorial in its etiology, uoride is an important
chemotherapeutic intervention to strengthen teeth and
prevent disease progression.2 The safety of uoride has
been demonstrated in numerous research studies and
community water uoridation heralded as one of the top 10
public health achievements of the 20th century by the
Figures 1-4
Centers for Disease Control and Prevention (CDC).3

How uoride prevents dental caries

Fluoride works to prevent dental caries through both topical

and systemic mechanisms via 3 processes: inhibiting tooth
demineralization, enhancing remineralization, and inhibiting
bacterial metabolism. Newer studies also suggest that
uoride interferes with bacterial adherence to the teeth.4 The
topical effect provides the majority of the bene t. Through
systemic mechanisms, the lesser effect, uoride is
incorporated into the tooth structure during tooth
development to harden the enamel and make more resistant
to demineralization.

What type of uoride is recommended

Table 1

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Topical uoride in the form of toothpaste (at-home use) and
varnish (in-o ce use) should be recommended for all
children starting at tooth eruption.2,5 The American
Academy of Pediatrics (AAP) and United States Preventive
Services Task Force (USPSTF) also recommends dietary
uoride supplements for all children who do not have an
adequate supply of uoride in their primary drinking water.
The AAP additionally recommends uoride mouth rinse use
Table 2
for children aged 6 years and older who are at high risk for
dental caries.2,6

TOPICAL FLUORIDE

Toothpaste: Fluoridated toothpaste is recommended upon

initial tooth emergence during infancy and throughout life.7,8
Do not recommend uoride-free “training toothpaste.”

1. From tooth emergence until age 3 years, a grain of rice-

sized (or “dab”) amount of uoride toothpaste should be Sample conversation on
used to brush the teeth both morning and night (Figure 1). fluoride use

2. For children aged older than 3 years, or when a child can

effectively spit, a pea-sized amount of uoride toothpaste should be applied morning and
night (Figure 2).

Children should be encouraged to spit after brushing. Post-brushing rinsing with water
should be limited to provide optimal uoride exposure to the teeth from the toothpaste.2,9
Fluoride toothpaste, like all other medications, should be kept out of reach of small children.

Mouth rinses: Over-the-counter uoride rinses may be bene cial for use for children,
particularly those who have high caries risk or live in uoride-de cient areas. Mouth rinses
should be reserved for high-risk children aged older than 6 years who can rinse and spit.2,10
Alcohol-containing mouth rinses should be avoided in pediatric populations.9 Fluoride
mouth rinses, supplements, or gels can be used after brushing with uoride toothpaste.

Varnish: Fluoride varnish is a highly concentrated form of topical uoride that is applied to
teeth in a professionally supervised setting. Research shows uoride varnish is highly
effective in caries reduction with a decrease in caries incidence between 18% to 24% in 1
study and as high as 59% in another.11,12 The USPSTF “recommends that primary care
clinicians apply uoride varnish to the primary teeth of all infants and children starting at the
age of primary tooth eruption” through age 5 years.6 The recommended uoride varnish
dose is 0.25 mL unidose 5% NaF (2.26% F), and frequency is every 3 to 6 months, based on
the child’s caries risk considerations.2,13 Fluoride varnish application is easy and fast. A thin
layer should be placed on relatively dry teeth achieved by wiping the teeth with gauze.

The steps in uoride application are:13

1. Assemble a light source, gauze, and varnish.

2. Use gauze to blot the teeth dry. Varnish does not adhere well to teeth if they are wet.

3. Prepare for application by stirring the varnish and apply varnish to dried teeth, starting on
the back teeth. Apply a thin layer to all tooth surfaces with the supplied brush.

4. Apply varnish to the front teeth last. Saliva contamination after application is expected
and varnish sets on contact with saliva (Figure 3).

5. Provide caregiver instructions about varnish application after care (Table 1).13

Instructional videos of proper uoride varnish application technique can be viewed online in
the National Smiles for Life Curriculum Module 613: www.smilesforlifeoralhealth.com.

Fluoride varnish application is a safe14,15 and effective16 procedure now reimbursed by

Medicaid in all 50 states and by private insurers in many states.13 In some states, not only
physicians and advanced practitioners but also nurses and medical assistants can apply the
varnish. In many states, trained individuals are available to instruct pediatric o ce
personnel on uoride varnish application. The AAP has a designated Chapter Oral Health

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Advocate in most states who can educate individuals and o ces on uoride varnish
application or provide support as questions arise about oral health integration into
practice.17

Developing a clinical work ow to include uoride varnish application can improve the oral
health of children within a practice. A recent Qualis Health White Paper offers speci c
strategies for integration of oral health into practice work ow.18

Other forms of topical uoride:

Dental providers may recommend other forms of topical uoride, including highly
concentrated uoride gels. However, these are generally not recommended for young
children aged younger than 6 years. In addition, silver diamine uoride is a modality now
being used in dentistry to help arrest caries in primary teeth.19,20

Community water uoridation:

Lastly, uoridated community water aids in prevention of dental caries by up to 27%21 and
reduces dental expenditures per capita22 by providing both topical and systemic routes of
uoride. Fluoridated tap water use should be encouraged instead of bottled water use,
which may not contain uoride and may be more acidic than previously anticipated, thus
promoting demineralization of tooth structure.23 Parents who live in areas with uoridated
water should be asked if their child drinks uoridated water. Parents often use bottled water
and therefore their children may not be receiving the bene ts of uoridated water. Pediatric
medical and dental providers should continue to strongly advocate for community water
uoridation as it bene ts not only children, but the entire population.24

SYSTEMIC FLUORIDE

The AAP recommends systemic (dietary) uoride supplementation in children aged 6

months to 16 years who live in areas where the primary water supply is uoride de cient. It
is important to ask about sources of uoride in a child’s diet, such as uoride in well water,
and the uoridation status of the local communities. Fluoride levels for well water should be
determined before prescription of uoride dietary supplements, as wells in some locations
may exceed the recommended uoride levels. For town water, the state Department of
Health or the CDC’s My Water’s Fluoride website are good resources to determine
uoridated amounts in the water supply throughout individual states.

Systemic uoride is usually prescribed by a medical or dental provider and comes in 2

forms, a liquid or a tablet. The liquid, most often used for young children aged younger than
3 years or whose primary molars are either not present or emerging, can be mixed with a
small amount of water or applied into the mouth directly onto the teeth. In older children, the
tablet is used and is available in 3 dosages: 0.25 mg uoride, 0.5 mg uoride, and 1 mg
uoride2 (Table 2). The tablet should be chewed or allowed to dissolve in the mouth for
optimal exposure of the teeth to uoride. Both the liquid and supplement should not be
given within 1 hour of milk products as calcium binds uoride and inhibits its absorption.25

Challenges

Inconsistencies remain in dietary uoride prescribing guidelines among national

organizations. The AAP and USPSTF recommend use of uoride supplements for all
children living in uoride-de cient areas, whereas the American Academy of Pediatric
Dentistry (AAPD) and the American Dental Association (ADA) recommend dietary uoride
supplementation only for children determined to be at high caries risk who drink uoride-
de cient water. Discrepancies in messaging between the medical and dental communities
present a clinical challenge for primary care providers and underscores the value of a
collaborative relationship between primary care and the local pediatric dental provider.
Some primary care providers choose to let dental providers develop the plan of uoride use
once a child has established a dental home.

The fear of uorosis has fueled some concerns about uoride use. Fluorosis occurs when
developing teeth are exposed to high quantities of uoride. Fluorosis presents as white
streaks or mottling on the tooth surface (Figure 4), with the milder presentations typically
not noticeable except by a trained dental professional.26 The risk of uorosis increases
when uoride is not used appropriately, such as eating large amounts of uoride toothpaste
during unsupervised brushing, or prescribing uoride to a child who already is drinking
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uoridated water. Recommend that caregivers always supervise young children during tooth
brushing and keep toothpaste in a safe location out of reach of young children, just like
other medications in the home.

Many other fears, such as uoride causing cancer or a low IQ, do not have a basis in
scienti c evidence. A good AAP website to refer to patients to help address these myths is
ilikemyteeth.org. It is important to understand concerns regarding uoride and seize the
opportunity to use motivational interviewing beginning with open-ended questions that
promote dialogue, such as: “What have you heard about uoride?” or “Help me understand
your concerns about uoride use.”

There may be times when you have given the family all the facts and they may continue to
refuse uoride. In these situations, it is best to make certain the patient has early and
consistent dental care to continue the discussion. Consistent messaging from the primary
care provider and dental specialists may help allay fears and encourage families to use
uoride.

Three strategies to consider are:

1. Reassure-Use language such as: “Fluoride is safe to use in appropriate amounts.”

2. Refer-Provide information from credible websites such as ilikemyteeth.org. Recommend

early establishment of a dental home to help deliver consistent messages about uoride
use.

3. Renegotiate-Consider alternate uoride usage routes if needed. Typical caregiver

concerns about uoride safety relate to ingestion of the product. As topical uoride is the
most bene cial, encourage compromise with use of limited uoride in toothpaste, varnish,
or mouth-rinse form.

Motivational interviewing is an exemplar for integration of oral health in primary care to

address caregiver worries and encourage ongoing discussion (see “Sample conversation on
uoride use”).

Take-home message for pediatricians

To summarize, uoride continues to be essential in caries prevention. Both topical and

systemic uoride play a role in maintaining good teeth and preventing oral disease, but the
topical effects are foremost. Primary care providers should be aware of the appropriate
uoride modalities to advise for children at each age and whether that recommendation is
universal or based on caries risk.

A well-informed pediatric provider can address concerns raised by uoride-hesitant families

through motivational interviewing and personalized communication. Early referral to
establish a dental home may help provide clarity about uoride use and improve dental
health. Consistent messaging from the medical and dental communities about oral health
and uoride use will promote optimal dental and overall health.

References:
1. Dye BA, Tan S, Smith V, et al. Trends in oral health status: United States, 1988-1994 and
1999-2004. Vital Health Stat 11. 2007;(248):1-92.

2. Clark MB, Slayton RL; Section on Oral Health. Fluoride use in caries prevention in the
primary care setting. Pediatrics. 2014;134(3):626-633.

3. US Department of Health and Human Services. Oral Health in America: A Report of the
Surgeon General. Executive summary. Rockville, MD: US Department of Health and Human
Services, National Institute of Dental and Craniofacial Research, National Institutes of
Health; 2000. Available at: https://www.nidcr.nih.gov/research/data-statistics/surgeon-
general. Reviewed January 2019. Accessed January 22, 2019.

4. Loskill P, Zeitz C, Grandthyll S, et al. Reduced adhesion of oral bacteria on hydroxyapatite

by uoride treatment. Langmuir. 2013;29 (18):5528–5533.

5. Weyant RJ, Tracy SL, Anselmo T, et al; American Dental Association Council on Scienti c
Affairs Expert Panel on Topical Fluoride Caries Preventive Agents. Topical uoride for caries
prevention: executive summary of the updated clinical recommendations and supporting
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x
systematic review. J Am Dent Assoc. 2013;144(11):1279-1291.

6. US Preventive Services Task Force. Dental caries in children from birth through age 5
years: screening. Recommendation summary. Rockville, MD: US Preventive Services Task
Force; 2014. Available at: www.uspreventiveservicestaskforce.org/uspstf/uspsdnch.htm.
Accessed January 22, 2019.

7. Dos Santos AP, Nadanovsky P, de Oliveira BH. A systematic review and meta-analysis of
the effects of uoride toothpastes on the prevention of dental caries in the primary dentition
of preschool children. Community Dent Oral Epidemiol. 2013;41(1):1-12.

8. American Dental Association Council on Scienti c Affairs. Fluoride toothpaste use for
young children. J Am Dent Assoc. 2014;145(2):190-191. Erratum in: J Am Dent Assoc.
2014;145(3):236.

9. American Academy of Pediatric Dentistry. Guideline on uoride therapy. Pediatr Dent.

2013;35(5):e165-e168.

10. Faller RV, Casey K, Amburgey J. Anticaries potential of commercial uoride rinses as
determined by uoridation and remineralization e ciency. J Clin Dent. 2011;22(2):29-35.

11. Lawrence HP, Binguis D, Douglas J, et al. A 2-year community-randomized controlled trial
of uoride varnish to prevent early childhood caries in Aboriginal children. Community Dent
Oral Epidemiol. 2008;36(6):503-516.

12. Weintraub JA, Ramos-Gomez F, Jue B, et al. Fluoride varnish e cacy in preventing early
childhood caries. J Dent Res. 2006;85(2):172-176.

13. Clark MB, Douglass AB, Maier R, et al. Smiles for Life: A National Oral Health Curriculum.
3rd ed. Society of Teachers of Family Medicine. 2010. Available at:
www.smilesforlifeoralhealth.com. Accessed January 22, 2019.

14. Beltrán-Aguilar ED, Goldstein JW, Lockwood SA. Fluoride varnishes: a review of their
clinical use, cariostatic mechanism, e cacy and safety. J Am Dent Assoc. 2000;131(5):
589-596.

15. Garcia RI, Gregorich SE, Ramos-Gomez F, et al. Absence of uoride varnish–related
adverse events in caries prevention trials in young children, United States. Prev Chronic Dis.
2017;14:e17.

16. Pahel BT, Rozier RG, Stearns,SC, Quiñonez RB. Effectiveness of preventive dental
treatments by physicians for young Medicaid enrollees. Pediatrics. 2011;127(3):e682-e689.

17. American Academy of Pediatrics. State information and resources map.

https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/Oral-
Health/Pages/State-Information-and-Resources-Map.aspx. Accessed January 22, 2019.

18. Hummel J, Phillips KE, Holt B, Hayes C. Oral Health: An Essential Component of Primary
Care. Seattle, WA: Qualis Health; June 2015. Available at:
http://www.niioh.org/sites/default/files/Oral_Health_white_paper_final.pdf . Accessed
January 22, 2019.
19. Fung MHT, Duangthip D, Wong MCM, Lo ECM, Chu CH. Randomized clinical trial of 12%
and 38% silver diamine uoride treatment. J Dent Res. 2018;97(2):171-178.

20. Crystal YO, Marghalani AA, Ureles SD, et al. Use of silver diamine uoride for dental
caries management in children and adolescents, including those with special health care
needs. Pediatr Dent. 2017;39(5):135-145. Available at:
http://www.aapd.org/media/Policies_Guidelines/G_SDF.pdf. Accessed January 22, 2019.

21. Gri n SO, Regnier E, Gri n PM, Huntley V. Effectiveness of uoride in preventing caries
in adults. J Dent Res. 2007:86(5);410-415. Available at:
http://www.ncbi.nlm.nih.gov/pubmed/17452559. Accessed January 22, 2019.

22. Ran T, Chattopadhyay SK; Community Preventive Services Task Force, Economic
evaluation of community water uoridation: a community guide systematic review. Am J
Prev Med. 2016;50(6):790-796.

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23. Wright KF. Is your drinking water acidic? A comparison of the varied pH of popular
bottled waters. J Dent Hyg. 2015;89(suppl 2):6-12.

24. Centers for Disease Control and Prevention. Community water uoridation. Available at:
https://www.cdc.gov/ uoridation/index.html. Reviewed October 4, 2016. Accessed January
22, 2019.

25. Buzalaf MA, Whitford GM. Fluoride metabolism. Monogr Oral Sci. 2011;22:20-36.

26. Pendrys DG. Risk of enamel uorosis in non uoridated and optimally uoridated
populations: considerations for the dental professional. J Am Dent Assoc. 2000;131(6):746-
755.

Download Issue : Vol 36 No 2

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