Clinical Integration of Osteopathic Manipulative Medicine

Pediatrics: Infant Cranial Deformities

Authors: Alissa Schurr, OMS-III, Patricia Kooyman, DO, and Sheldon Yao, DO

Introduction: Deformation of the skull to varying degrees is a common finding among newborns and infants. It can be provoked by either extrinsic (non-synostotic) or intrinsic (synostotic) forces. Extrinsically, forces placed upon the skull during birth or by excessive time spent lying on one side (either during gestation or postnatally) can lead to a misshapen, yet non-synostotic, cranium. The most common non-synostotic cranial deformities include occipital plagiocephaly, or flattened occiput, followed by brachycephaly, in which the flattened occiput produces a widened head shape with bulging forehead.1 On the other hand, craniosynostosis accounts for infant cranial deformities caused by intrinsic forces, and is defined by premature closure of the fontanelles. Numerous categorizations of synostotic cranial deformity exist, including scaphocephaly, trigonocephaly, and acrocephaly, among others. Each of these is classified based on which suture fused prematurely. Diagnosis of infant cranial deformity is typically based on physical exam findings; however, radiologic imaging with a 3D CT scan can further illustrate the deformity, and in cases of craniosynostosis, can pinpoint which sutures have actually prematurely closed. Approximately twenty percent of cases of craniosynostosis are associated with a genetic disorder.2 The investigators involved in a Canadian study found that, in infants 7‒12 weeks of age, the incidence of non-synostotic plagiocephaly was approximately 46.6%, which emphasizes the considerable frequency of this diagnosis.3 Notable risk factors include a history of complicated birth (e.g. use of forceps, multiple births, prematurity), supine sleep position, torticollis, and male gender. Occipital plagiocephaly has been linked to the “Back to Sleep” campaign, which strongly encourages a supine sleeping position for infants in order to decrease the incidence of sudden infant death syndrome (SIDS).4 RH Woods previously noted an association among several parameters, including history of complicated birth, cranial somatic dysfunction, and certain neuropsychological disturbances in childhood. These neuropsychological disturbances include concentration difficulty, learning disabilities, and poor school performance.5,6 Former observational studies cited by Lessard et al. have suggested a possible link between plagiocephaly and issues related to postural compensations and visual dysfunctions.7 These findings highlight the importance of treating cranial deformities while the infant’s skull is still malleable. Treatment options usually depend on the severity of the cranial deformation and the cephalic ratio (ratio of cranial width to cranial anteroposterior length), but typically include repositioning techniques, physical therapy, and cranial orthotics (i.e. helmet therapy).1

Patient Presentations: Parents of an infant, or infants in the case of twin or multiple births, may initially present to the pediatrician’s office with their concerns regarding the shape of their infant’s skull, as well as any number of other associated concerns regarding their infant (or infants, as the case may be). Infant cranial deformity is typically noticeable by gross examination. The infant may or may not exhibit any behavioral changes indicative of other symptoms. If the pediatrician suspects a craniosynostosis, then the appropriate pediatric neurosurgical referral is provided for the parents. For non-synostotic deformations, compression of various portions of the four parts of the occiput during the vaginal birth process can potentially affect the Vagus nerve (CN X), manifesting in vomiting and irritability, or the Hypoglossal nerve (CN XII), manifesting in poor sucking.8 The infant’s head may be persistently tilted if the cranial asymmetry is due to a torticollis related to an Accessory nerve (CN XI) compression. If the cranial asymmetry is secondary to a chromosomal abnormality, other malformations associated with the disorder are likely to be found. For example, a child with Down syndrome may have low-set ears and epicanthal folds, along with brachycephaly.2 For the non-synostotic infant cranial deformity presentations described above, it should be noted that treatment at the early infant phase of life can provide relief, improvement, and decreased deformity.

Differential Diagnosis: • Plagiocephaly • Non-synostotic brachycephaly • Craniosynostosis o Brachycephaly (fused bilateral lambdoid sutures) o Scaphocephaly (fused sagittal suture) o Trigonocephaly (fused metopic suture) o Acrocephaly (fused lambdoid and coronal sutures) Alternate name: Oxycephaly o Kleeblattschädel (fused sagittal, coronal, and lambdoid sutures) Alternate name: Cloverleaf skull • Cranial strain (often lateral strain or SBS compression) • Chromosomal abnormality • Microcephaly • Macrocephaly • Caput succedaneum • Cephalohematoma • Abusive head trauma

Clinical Pearls: • Evaluation of infants and children presents unique challenges such as stranger anxiety and threat of harm—engaging in play can elicit cooperation. Distraction can also prove useful.8 • The interrelationship between structure and function plays a key role in pediatrics— somatic dysfunctions in a pediatric patient can hinder his or her optimal growth and development. Thus, structural issues should be attended to early in life.8 • At birth, many of the cranial bones are segmented and cartilaginous. There are six major fontanelles located between the bones of the cranial vault.7 • The developing and newborn skull lacks any articulations, so the dura maintains the shape and stability of the cranium.

OMM Integration: Historically, treatment recommendations for plagiocephaly have included repositioning maneuvers, physical therapy, cranial orthotics, and surgery, if necessary. With respect to cranial orthotic treatment, the general course is for the infant to wear a custom helmet for twenty-three hours per day for 3 ‒ 6 months.1 Osteopathic manipulation can be incorporated into the treatment of cranial asymmetries in infants, ideally as an alternative to cranial orthotics. The goal of osteopathic treatment is to optimize symmetrical growth of the pediatric infant patient and to remove any potential barriers to proper cranial maturation.7 Pediatrician Miriam Mills, MD published a letter in The Journal of Pediatrics in 2006 urging the pediatric community to consider using an osteopathic approach for the treatment of plagiocephaly. She promoted the safety, efficacy, and positive toleration in treating various pediatric conditions with osteopathic cranial manipulative medicine.9 The osteopathic perspective not only includes the physically apparent issue of infant cranial non-synostotic deformity and any associated discomfort to the infant, but also considers potential influences on the infant’s development in relation to the central nervous system (including nerve compressions or entrapments) and the clinical consequences. A pilot study by Lessard and colleagues was conducted on twelve infants with occipital plagiocephaly in which each infant was treated with osteopathic manipulative treatment (OMT) for four sessions over the course of two months.7 Cranial measurements were performed prior to the first treatment, at the time of the third treatment, and two weeks after the fourth treatment. It was found that there was a significant decrease in cranial vault and skull base asymmetry by the final evaluation, as compared to the initial measurements. These promising results warrant the conduction of more clinical treatment outcome studies, and the consideration of OMT in the treatment of infant cranial deformity.

Osteopathic Structural Exam: • Gross visual assessment of cranium • Palpation of fontanelles and regions of future sutures • Cranial vault (assess for cranial base strain patterns) • Occipital contact (assess the cranial base) • Occipital condylar portions (assess for any dysfunctions) • Tonicity of sternocleidomastoid muscles • Cervical spine • Sacrum and pelvis • Primary respiratory mechanism (assess the inherent motion)

Possible Osteopathic Treatment Options: • Condylar decompression • Release of cranial strain patterns • Intraosseous molding • Cranial base treatment • Basilar expansion • Myofascial release (muscles of the neck) and soft tissue techniques • Treatment of shoulder girdle • Lumbosacral decompression • Treatment of sacrum and pelvic girdle • Repositioning (e.g. additional ‘tummy time’) and positioning maneuvers

References: 1. Lam S, Pan I-W, Strickland BA, et al. Factors influencing outcomes of the treatment of positional plagiocephaly in infants: a 7-year experience. Journal of Neurosurgery: Pediatrics. 2017;19(3):273-281. doi:10.3171/2016.9.peds16275. 2. Lewis ML. A Comprehensive Newborn Examination: Part I. General, Head and Neck, Cardiopulmonary. American Family Physician. 2014;90(5):289-296. https://www.aafp.org/afp/2014/0901/p289.html. 3. Mawji A, Vollman AR, Hatfield J, McNeil DA, Sauve R. The Incidence of Positional Plagiocephaly: A Cohort Study. Pediatrics. 2013;132(2):298-304. doi:10.1542/peds.20123438. 4. De Bock F, Braun V, Renz-Polster H. Deformational plagiocephaly in normal infants: a systematic review of causes and hypotheses. Archives of Disease in Childhood. 2017;102(6):535-542. doi:10.1136/archdischild-2016-312018. 5. Woods JM, Woods RH. A physical finding related to psychiatric disorders. Journal of the American Osteopathic Association. 1961; 60: 988-993. 6. Woods RH. Structural normalization in infants and children with particular reference to disturbances of the central nervous system. Journal of the American Osteopathic Association. 1973;72: 903–908. 7. Lessard S, Gagnon I, Trottier N. Exploring the impact of osteopathic treatment on cranial asymmetries associated with nonsynostotic plagiocephaly in infants. Complementary Therapies in Clinical Practice. 2011;17(4):193-198. doi:10.1016/j.ctcp.2011.02.001.* 8. Magoun MA, Picca AJ, Leonor JO, et al. 42B: Osteopathic Considerations in Pediatrics. In: Seffinger MA, ed. Foundations of Osteopathic Medicine: Philosophy, Science, Clinical Applications, and Research. 4th ed. Philadelphia, PA: Wolters Kluwer; 2018. 9. Mills MV. Consider osteopathic manipulation in next positional plagiocephaly research. The Journal of Pediatrics. 2006;148(5):706-707. doi:10.1016/j.jpeds.2005.06.014 .

*Indicates a related evidence-based medicine article.