Thank you for the constructive feedback on our review article Positional Skull Deformities, which we are glad to address (1).
The relationship between the entirely sensible recommendation for infants to be always placed on their backs to reduce the risk of sudden infant death syndrome and the development of positional skull deformities has been confirmed (2). As stated, one of the possible causes is limited movement, sometimes related to birth traumas. Kinetic imbalances due to suboccipital strain (KISS syndrome) are not seen as a defined disease pattern by the German Society for Pediatric Neurology (Deutsche Gesellschaft für Neuropädiatrie) (3). Deutsches Ärzteblatt requests authors to base articles such as ours on existing, evidence-based recommendations. As described in the article, limited range of motion of the head is often the cause of positioning plagiocephaly and should therefore be treated promptly. Such treatment may include physiotherapy or manual therapy, for example. As quoted in current US guidelines, we have included this point under the heading of physiotherapy (4)—the term “osteopathy” is not used. When range of motion of the head is limited, we recommend prompt physiotherapy, manual therapy, or osteopathy to the parents of our patients. As stated, stage-appropriate treatment should be selected; helmet therapy is usually the treatment option of last resort. Because a cranial orthosis that molds the skull does not treat the cause of limited range of motion of the head, we believe it is important to continue with physiotherapy, manual therapy, or osteopathy in parallel to helmet therapy. The explicit advice is not to use mobile positioning aids such as rings or cushions, due to the risk of sudden infant death (2).
The issue of development delays in affected children is certainly a fascinating and highly controversial subject. As Dr. Riedel rightly states, there are studies that indicate a correlation. Unfortunately, none of the available studies addresses the question of cause and effect: was there first a developmental delay which resulted in a positional skull asymmetry, or does a positional skull deformity lead to developmental delays? In addition, the case numbers investigated are small, and only some studies are controlled. Our own recent research, in which we investigated early language development in affected children and children in a control group, found no differences between the two groups (5, 6). These findings are in line with our clinical impression. However, the question of neurocognitive effects of positional skull deformities can certainly not yet be answered conclusively, and further studies on this are needed.
In discussing the cause, effects, and treatment of positional skull deformities it is important to maintain the recommendation to place infants on their backs and to educate parents promptly and comprehensively. Worries or lack of awareness concerning the development of skull deformities should under no circumstances lead to this sensible recommendation being rejected.
PD Dr. med. Dr. med. dent. Christian Linz
Klinik und Poliklinik für Mund-, Kiefer- und Plastische Gesichtschirurgie
PD Dr. med. Tilmann Schweitzer
Conflict of interest statement
The authors of all contributions declare that no conflict of interest exists.
|1.||Linz C, Kunz F, Böhm H, Schweitzer T: Positional skull deformities— etiology, prevention, diagnosis, and treatment. Dtsch Arztebl Int 2017; 114: 535–42 VOLLTEXT|
|2.||AAP Task Force on Sudden Infant Death Syndrom: SIDS and other sleep-related infant deaths: evidence base for 2016 updated recommendations for a safe infant sleeping environment. Pediatrics 2016; 138 pii: e20162940.|
|3.||Karch D, Boltshauser E, Groß-Selbeck G, Pietz J, Schlack HG: Behandlungsverfahren bei Entwicklungsstörungen und zerebralen Bewegungsstörungen. Manualmedizinische Behandlung des KISS-Syndroms und Atlastherapie nach Arlen; Stellungnahme der Gesellschaft für Neuropädiatrie e. V. Manuelle Medizin 2005; 43: 100–5 CrossRef|
|4.||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: 623–4 CrossRef MEDLINE|
|5.||Linz C, Schweitzer T, Brenner LC, Kunz F, Meyer-Marcotty P, Wermke K: Does shape affect function? Articulatory skills in babbling of infants with deformational plagiocephaly. Childs Nerv Syst 2017 (Epub ahead of print) CrossRef MEDLINE|
|6.||Wermke K, Linz C, Hasenberg A, Kunz F, Meyer-Marcotty P, Schweitzer T: Six month-old infants with deformational plagiocephaly do not differ from unaffected infants with respect to vocal control. Intl J Ped Otorhinolaryng 2017; 102: 15–20 CrossRef MEDLINE|