Testing Guidelines for Child Health Care Nurses to Prevent Nonsynostotic Plagiocephaly: A Swedish Pilot Study

doi:10.1016/j.pedn.2010.04.005

Journal of Pediatric Nursing

Volume 26, Issue 6, December 2011, Pages 541-551

https://doi.org/10.1016/j.pedn.2010.04.005 Get rights and content

The aim of the study is to test effectiveness of guidelines for nurses that can be incorporated into the child health care program to prevent nonsynostotic plagiocephaly (NSP) in infants while still following sudden infant death syndrome-preventive recommendations. When guidelines were followed as intended in a Swedish pilot study, only 8.5% of infants had some degree of NSP at 6 months, compared to 25.6% of infants in the comparison group. Results indicate that the early and regular implementation of these guidelines by nurses may be an effective way to prevent NSP.

Section snippets

Nursing Framework

An evidence-based practice paralleling the nursing process (Hockenberry, Wilson, & Barrera, 2006) was implemented in a Swedish pilot study. After identifying the problem, relevant information was collected, compiled, and analyzed. Evidence was then applied to the practice and subsequently evaluated for effectiveness.

Guidelines

Recommendations and background information found in peer-reviewed articles from health profession journals and relevant for clinical nursing practice were selected and compiled into

Results

There were 99 infants in the pilot study. The results of the nursing assessments and nursing interventions are presented for each monthly visit in Table 2. All nurses and all families followed through the entire study. There was some missing data because 8 infants missed 1 or more visits. Assessments were occasionally missed for some other reasons. Nurses were expected to assess infants regularly, to advise parents at the first visit and to counsel parents whenever high-risk signs for NSP were

Discussion

Volunteer nurses were recruited to minimize nonresponse. All the nurses and families who agreed to participate in the pilot study followed through the study. The evidence that the guidelines can be incorporated into the existing child health care program can be seen when noting that the 99 infants were assessed on 580 occasions and parents were given advice on 265 occasions. Nurses working within this program have an excellent opportunity to intervene in NSP prevention because of the frequency

Clinical Implications and Conclusions

Child health care nurses in Sweden are the infants' primary health care providers and have a key role in preventing NSP. Results of the pilot study indicate that these simple strategies can be incorporated into the existing Swedish child health care program, and providing nurse clinicians with guidelines and more education on NSP can help them to work effectively with parents to prevent NSP in infants. Early and regular assessments of the infant cranial form and early advice to parents are also

Acknowledgments

The author wishes to thank the parents, infants, and nurses who participated in the pilot study and the health center administration for providing funding for the ethics committee fee. The author also wishes to thank Dr. Henri Toivonen, Medical Head of the Child Healthcare Department in Skaraborg, who served as medical consultant; Anna Öhman, PhD, Queen Silvia Hospital in Gothenburg, for advice and for sharing her knowledge of NSP; Per Nordin at the Skaraborg Institute for advice on methods and

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Cited by (18)

Another look at “tummy time” for primary plagiocephaly prevention and motor development
2023, Infant Behavior and Development
It is three decades since it was recommended that infants sleep on the back to reduce risk of sudden unexpected infant death (SUID). The SUID prevention program is known as “back to sleep” or “safe sleeping”, and this initiative is not questioned. Sleeping on the back is associated with, but not the cause of, the development of infant positional plagiocephaly, also known as deformational or a non-synostotic misshapen head when the skull sutures are open, not fused. This paper provides a synthesis of the history and impact of positional plagiocephaly. It includes a scoping review of plagiocephaly prevention facilitating motor development and reveals few articles on primary prevention which aims to prevent it developing in the first place. It is concerning that preschool-aged children with a history of infant plagiocephaly continued to receive lower developmental scores, particularly in motor development, than unaffected controls, and this may be a marker of developmental delay. Tummy-time (prone) for play is the mainstay of plagiocephaly prevention advice to minimize development of plagiocephaly and to facilitate infant motor development, particularly head control. While tummy-time has shown benefit for infant development, there is limited evidence of its effectiveness in preventing plagiocephaly and some evidence that it promotes only prone-specific motor skills. Most of the published literature is concerned with treatment post-diagnosis, in the form of reviews, or clinical notes. There is a plethora of opinion articles reinforcing tummy-time from birth for plagiocephaly prevention. The review shows that there are gaps in advice for early infant development of head control. An accepted test of head control in infants is “pull to sit” from supine which demonstrates antigravity strength of the neck flexors and coordination of the head and neck when the infant is drawn to sit from supine. This motor skill was cited as achievable by 4 months in the earliest paper on plagiocephaly in 1996. Physical therapists and others should revisit the mechanism of early infant head control development against gravity, particularly antigravity head, neck and trunk coordinated flexion movement in supine, as there has been little attention to early facilitation of this motor skill as a plagiocephaly prevention strategy. This may be achieved by considering “face time” as well as tummy time for primary prevention of plagiocephaly.
The PLAY bundle for head deformities: A NICU quality improvement project
2023, Journal of Neonatal Nursing
Premature infants in the Neonatal Intensive Care Unit (NICU) have a greater risk of head deformities and related complications. Numerous evidence-based interventions demonstrate successful prevention and treatment for head deformities with maximized success when combined.
There was no standardized policy to aid in the prevention, evaluation, and management of head deformities at a local children's hospital. Additionally, the Electronic Health Record (EHR) did not optimize head measurement documentation and documented asymmetrical head measurements did not prompt follow-up.
Authors developed a nurse-driven order set, or bundle, comprised of Positioning and PT/OT involvement, Learning, Assistive Devices, and You (PLAY) as part of a quality improvement project to reduce the progression of head deformities through education, prevention strategies, and earlier identification and treatment. Data collected for the first 13 weeks was under the current standard of care and data collected under the second 13 weeks was under the PLAY bundle.
33 infants participated with 19 after PLAY Bundle implementation. Under the current standard of care, 34% of patients (n = 27) had plagiocephaly documentation while just 7% (n = 6) received a PT (Physical Therapist) consultation. Of the participants diagnosed with head deformities since PLAY Bundle implementation, biweekly head measurements improved in 58%, worsened in 20%, worsened then improved in 8%, and stayed the same in 20%.
The PLAY Bundle was successful in the earlier identification and intervention of head deformities. In addition, the PLAY Bundle highlighted the importance of repositioning intervention for head deformities.
Deformational Plagiocephaly—A Focus on Prevention
2017, Journal for Nurse Practitioners
Citation Excerpt :
Common barriers to achieving the recommended total of 30-60 minutes of “tummy time” per day13 include a perceived lack of time for caregivers to provide adequate supervision and infants’ negative responses to the prone position.17 Strategies to overcome these obstacles include the breakdown of “tummy time” into several 10- or 15-minute sessions,16 the early initiation of very short sessions that slowly increase over time, the addition of toys to keep the infant engaged, the caregiver joining the infant on the floor, and lying the child prone on the caregiver’s chest until they become more accustomed to this position.22 Other methods of prevention include using infant car seats only when traveling in a motorized vehicle and limiting the time infants spend in swings or other recreational activities that restrict movement and cause pressure on the occiput.11
Deformational plagiocephaly is a common issue in primary care. It is crucial that providers are familiar with recommendations for the diagnosis and management of DP. In this article we provide an overview of literature related to epidemiology, risk factors, clinical presentation, differential diagnosis, history and physical, diagnostics, management, screening, prevention, and associated delays in development. As deformational plagiocephaly is an avoidable condition, we stress the importance of early screening and present strategies for prevention.
Teaching Parents How to Prevent Acquired Cranial Asymmetry in Infants
2016, Journal of Pediatric Nursing
Citation Excerpt :
Did parents learn more details of NSP prevention when their child health nurses had participated in our program? In an attempt to prevent NSP, guidelines for child health nurses working with parents of infants were developed in a literature study (Lennartsson, 2011a), tested in a pilot study (Lennartsson, 2011b), and revised. A short educational program incorporating these revised guidelines was subsequently developed for these nurses who are public health nurse specialists or pediatric nurse specialists.
Acquired cranial asymmetry is prevalent in infants today. This is largely attributed to the supine sleep position recommended for infant safety. The condition can become permanent, so prevention and early detection are important. A prevention project was initiated where guidelines for Swedish child health nurses were developed, tested in a pilot study, revised, and then incorporated into a short cranial asymmetry prevention program for nurses. The program included detailed information on what to teach parents of newborns. An intervention study was initiated where one group of nurses was taught according to the program and the other group followed the standard recommendations. The aim of this survey was to compare intervention and control group parents’ responses regarding the cranial asymmetry prevention information that they had received from their nurses during their infant’s first four months. Participants included 272 parents (180 intervention group, 92 control group) at 26 child health centers. A checklist was distributed to parents in conjunction with infants’ four month health checkup. A significantly higher percentage of intervention group parents were aware of regular recommendations – alternate direction of the infant’s head when putting the child to bed (82%: 64%, p = 0.001), which pillow to use (92%: 80%, p = 0.01), and when to remove the pillow (48%: 31%, p = 0.006) – and five newly introduced recommendations compared to controls. Results indicate that educating child health nurses on prevention of cranial asymmetry works to increase parental awareness of what to do and how to do it safely.
Translational research: Creating excellent evidence-based pediatric nursing practice
2011, Journal of Pediatric Nursing
Nonsynostotic plagiocephaly: Prevention strategies in child health care
2020, Journal of Clinical Medicine

View all citing articles on Scopus

¹: Previous presentation: The study was presented as a thesis for Master of Science in Nursing degree and was defended on May 25, 2009, for an opponent and a group of 10 other individuals at the University of Skövde, School of Life Sciences, Sweden. Several revisions have been made in the manuscript since May 25th.

²: Author information: Freda Lennartsson, American and (recently became a) Swedish citizen, born and raised in Pennsylvania, USA; graduated from the University of Delaware, College of Nursing in December, 1976; moved to Sweden 1977; became a pediatric nurse specialist 1984 and a public health nurse specialist 1993; has primarily lived and worked in Sweden as a nurse since 1977; also volunteer pediatric nursing work at Kilimanjaro Christian Medical Center, Moshi, Tanzania 1985–1986; school health project for Save the Children Sweden at the Asfaw Yemiru School in Addis Ababa, Ethiopia 1988–1990; currently employed part time as a clinical nurse specialist at Götene's Child Health Care Center and working 1 day per week at the University of Skövde School of Life Sciences as a co-opted nursing instructor; completed studies for Master of Science in Nursing degree in 2009.

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Testing Guidelines for Child Health Care Nurses to Prevent Nonsynostotic Plagiocephaly: A Swedish Pilot Study1,2

Section snippets

Nursing Framework

Guidelines

Results

Discussion

Clinical Implications and Conclusions

Acknowledgments

Seminars in Pediatric Neurology

Conservative interventions for positional plagiocephaly: A systematic review

Developmental Medicine and Child Neurology

Diagnosis and management of positional head deformity

American Family Physician

Barnhälsovård [Child health care]

Swedish child heath care in a changing society

Scandinavian Journal of Caring Sciences

Implementing Evidence-Based Nursing Practice in a Pediatric Hospital

Pediatric Nursing

Impacting infant head shapes

Advances in Neonatal Care

Plagiocephaly and brachycephaly in the first two years of life: A prospective cohort study

Pediatrics