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Testing Guidelines for Child Health Care Nurses to Prevent Nonsynostotic Plagiocephaly: A Swedish Pilot Study
Journal of Pediatric Nursing (2011) 26, 541–551
Testing Guidelines for Child Health Care Nurses to Prevent Nonsynostotic Plagiocephaly: A Swedish Pilot Study1,2 Freda Lennartsson RN, MSN ⁎ Primärvården Skaraborg, Sweden and School of Life Sciences, University of Skövde, Skövde, Sweden
Key words: Infant-adapted pillow; Occipital flattening; Nonsynostotic plagiocephaly; Sudden infant death syndrome
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. © 2011 Elsevier Inc. All rights reserved.
THE NEWBORN'S CRANIUM is thin and soft and can easily become altered from a unilateral head position on a firm surface, resulting in compensatory bulging elsewhere due to the brain's intense growth during the child's first year (Lauritzen & Tarnow, 1999). Nonsynostotic plagiocephaly (NSP) is a condition in which the back of an infant's head becomes altered as the result of external forces applied to the
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. ⁎ Corresponding author: Freda Lennartsson, RN, MSN. E-mail addresses: [email protected], [email protected].
0882-5963/$ – see front matter © 2011 Elsevier Inc. All rights reserved. doi:10.1016/j.pedn.2010.04.005
malleable cranium. This can occur prenatally or postnatally (Littlefield, Saba, & Kelley, 2004) and often progresses to an asymmetric cranium, ear misalignment, and facial asymmetry (Littlefield, Kelly, Pomotto, & Beals, 2002). The first 4 months seem to be the critical period for the development of NSP acquired after birth (Hutchison, Hutchison, Thompson, & Mitchell, 2004). There has been a steady increase in referrals for NSP following the American Academy of Pediatrics' (AAP) recommendation in 1992 of a supine infant sleeping position to prevent sudden infant death syndrome (SIDS), largely because of poor parent education on the risks of prolonged occipital pressure (Morrison & Chariker, 2006). NSP may self-correct as the infant becomes more mobile, but this is not always the case. A noticeable asymmetric face is often considered less attractive, and the psychosocial developmental consequences of uncorrected severe deformities can be significant (Hummel & Fortado, 2005). There is no conclusive evidence regarding which interventions are most effective in reducing NSP, although counterpositioning in conjunction with physiotherapy and/or helmet therapy was identified as a promising trend according to Bialocerkowski, Vladusic, and Howell (2005). This condition is fairly easy to manage when diagnosed early; treatment can become more difficult and complicated with a prolonged course (Morrison & Chariker, 2006). It is important to differentiate NSP from
542 the rare congenital condition lambdoid synostosis, where occipital flattening occurs from the premature fusion of a cranial suture, and surgery is nearly always indicated (Kabbani & Raghuveer, 2004). The Swedish child health care system is voluntary, free of charge, and an integrated part of primary health care. The attendance rate is nearly 100% according to Hallberg, Lindbladh, Petersen, Råstam, and Håkansson (2005), who refer to a Swedish National Report from 1994. Public health or pediatric nurse specialists work in the approximately 3,000 Swedish child health care centers. Once the newborn is discharged from hospital care, these clinical nurse specialists are the primary health care providers until the child is 6 years of age. It is their responsibility to monitor the child's health and development and to support parents in their parental role. During the infant's first 6 months, nurses assess the child at least 9 times according to the program. (Hagelin, Magnusson, & Sundelin, 2007, pp. 39–45). Following national recommendations, Swedish child health care nurses have advised parents since 1992, among other factors, to lay their infant supine while sleeping to prevent SIDS. Although the AAP discourages the use of pillows in the infant's sleeping environment (Persing et al., 2003; Task Force on Sudden Infant Death Syndrome, 2005), the Swedish National Board of Health and Welfare recommends using an infant-adapted pillow for supine sleeping babies until they are 3 to 4 months of age to concurrently prevent NSP. The soft thick pillow is to be taken away when the infant begins to turn over and may be replaced by a firm, flat infant pillow (Socialstyrelsen, The National Board of Health and Welfare, 2006). Placing the infant prone for play is also recommended nationally. Yet, the problem of NSP persists even in Sweden (Öhman & Beckung, 2005; Öhman, Nilsson, Lagerkvist, & Beckung, 2009). The aim of the pilot study was to test effectiveness of nursing guidelines that can be incorporated into the existing Swedish child health care program to prevent NSP while concomitantly following established SIDS preventive measures. The hypothesis is that early and regular nursing assessments and advice given to parents early and when high-risk signs are present will prevent NSP and resolve cases where occipital flattening has already occurred.
Methods 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.
F. Lennartsson
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 guidelines for nurses that could be incorporated into the existing Swedish child health care program (Appendix A).
Participants and Setting To recruit volunteers, child health care contact nurses in Skaraborg were informed about the pilot study in May 2008 and were asked to inform their coworkers. There are 78 public health and/or pediatric nurse specialists working in 27 child health care centers in the Skaraborg area of Sweden (Navet, Skaraborg Primary Care Intranet homepage, personal access, 2008), and 19 of these nurses, working at 7 child health care centers, volunteered to participate. These nurses were all given a copy of the guidelines and were offered a clinical visit for verbal information. Thirteen of the nurses at 5 clinics accepted the offer of verbal information where the guidelines and study were explained; a doll and infant pillow were used to demonstrate correct infant positioning, and nurses were given an opportunity to ask questions. Nurses informed parents with newborns born during September and October of 2008 in their districts about the study. All infants in the respective districts whose parents provided written informed consent were included. There were 99 infants in the study.
Data Collection Nurses filled in a checklist (Appendix B) each time an infant was brought to the monthly visit until the child was 6 months of age. The presence of any observed occipital flattening, a one-sided bald spot, a parallelogram head form, head tilt, and side preference were the recorded signs assessed by nurses. Advice to parents and referral to a pediatrician were the recorded nursing interventions. Assessment scales were not used.
Data Analysis A database was set up. Seven discrete variables were recorded during the infants' six monthly visits. Five variables were nursing assessments. Two of these assessment variables, flattened occipital spot and parallelogram head form, are signs of some degree of NSP. Infants with some degree of NSP during at least one assessment were referred to as cases. Three assessment variables, asymmetric bald spot, head tilt, and side preference, are potential risk factors. These five variables are all signs that should alert the nurse to potential risk for NSP development. Assessed infants observed to have at least one of these five signs were considered infants with high risk for NSP development. The
Testing Guidelines to Prevent NSP: A Swedish Pilot Study Table 1 The Retrospective Infant Groups in the Swedish Pilot Study to Prevent Infant Occipital Flattening From September 1, 2008, Until May 11, 2009
Infants Who Were Exposed to Nursing Actions as Intended 59 infants They were brought to and assessed during each monthly visit Their parents received nursing advice on NSP prevention at the first visit Their parents received nursing advice whenever signs of highrisk for NSP were present
Infants in the Comparison Group Who Were Not Exposed to All Intended Nursing Actions for Some Reason 40 infants One or more visits or assessments were missed Their parents did not receive nursing advice on NSP prevention at the first visit Nursing advice was not documented although a sign of high-risk for NSP was present
final two variables, advice given to parents and referral made to a pediatrician, were nursing interventions. The relationship between nursing interventions, high risk for NSP development, and cases was examined over time. To evaluate the guidelines, infants were divided retrospectively into two groups, the 59 infants who were exposed to nursing actions in which guidelines were followed as intended and a comparison group, where 40 infants were exposed to nursing actions where guideline intentions were not fully met (Table 1). Infants in the group where guidelines were followed as intended were brought to and assessed at each of the six visits, and their parents received advice at the first visit and received advice whenever signs of high risk for NSP were present. In the comparison group, the infants were not assessed regularly for some reason and/or parents did not receive early advice or did not receive advice when their child showed signs of high vulnerability for NSP development. The guidelines were evaluated by comparing outcomes of head shape in relation to nursing actions when the infants were 6 months old. The fewer NSP cases persisting at age 6 months when infants were exposed to nursing actions as intended, the better the indication of the guideline effects. A
543 hypothesis test was performed. The relationship between nursing actions and outcome of infants' head shape at age 6 months was analyzed using the chi-square test for the infant population. Among these infants, case infants were identified. The relationship between nursing actions and outcome of head shape was also analyzed for this subgroup. These samples were not mutually exclusive. P values of .05 or less were considered statistically significant findings. A post hoc power analysis was also performed.
Ethical Considerations and Permission A letter to parents was formulated to explain who was responsible for the collected information and to promise complete confidentiality. The study design was approved by the Medical Head of the Department of Child Health Care in Skaraborg. An ethical advice statement was then obtained from the Regional Ethics Committee in Gothenburg, who interpreted the study to be important for the prevention of both NSP and torticollis. They warned against frightening parents, so inconclusive evidence regarding possible developmental problems was omitted from the study. Written permission was subsequently obtained from the Head of Department at each health care center where participating nurses were employed. Parents of newborns then received both verbal and written information from their child health care nurses that, in addition to the confidentiality assurance, included the study's purpose and an assurance that participation was voluntary and that participants had a right to discontinue without any repercussions. Written informed parental consent was procured before a newborn was included in the study. SIDS prevention work continued as usual throughout the study.
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
Table 2 Nursing Assessments and Interventions During the Pilot Study to Prevent Infant Occipital Flattening From September 1, 2008, Until May 11, 2009, at 7 Child Health Care Clinics in Sweden Nursing Assessment: No. of Infants Presenting High-Risk Signs for Occipital Flattening
Infant Age at Visit (No. of Infants Assessed Flattened Asymmetric Occipital Side at Each Visit. N = 99) Occipital Spot Bald Spot Preference 1 month (n = 95) 2 months (n = 96) 3 months (n = 98) 4 months (n = 96) 5 months (n = 97) 6 months (n = 98)
2 4 16 24 22 15
0 3 8 12 11 6
7 15 12 8 3 1
Head Tilt 2 3 4 3 2 2
Nursing Intervention: No. of Occasions Parallelogram Advice Given Head Form to Parent 0 1 1 2 0 0
67 44 55 41 32 26
Referral to Pediatrician 0 0 1 2 0 3
544 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 present, and to carefully follow these infants, but this was not always the case. Only 67 of 99 infants' parents received advice at the first visit according to checklists, and not all parents were counseled when infants showed high-risk signs for NSP development. The relationships among nursing advice to parents, infants with at least one recorded sign of high risk for NSP development, cases present and referrals made to a pediatrician at each visit are illustrated in Figure 1. At 2 months, when nursing advice decreased, the number of cases began to rise. The number of cases continued to rise and peaked at 4 months, whereas advice decreased from 3 months on. The aim of the guidelines is to prevent NSP, yet 15% of the infants still had some degree of NSP at 6 months of age. Many high-risk infants became cases. Consistent with instructions, five infants were referred to a pediatrician, of whom four were case infants who failed to improve, and the fifth was referred for suspected torticollis when head tilt was detected at 6 months. A pediatrician was consulted twice for one of these infants. Table 3 illustrates tendencies in the course and occipital outcome for infants with the following high-risk signs: an asymmetrical bald spot, head tilt, side preference, and a parallelogram head shape. Twenty infants had an asymmetric bald spot at some point. Fourteen of them presented other high-risk signs either before, in conjunction with, or after hair growth had filled in the spot. Two of these infants had flattened spots at 6 months of age. Six infants had head tilt at some point. Three recovered, 1 had a flat spot at 6 months, and 2 were referred to a pediatrician. Two of the infants with head tilt also showed side preference, 2 had flat spots, and 1
Figure 1 Relationship between nursing interventions, presence of at least one sign of high risk for occipital flattening, and development of cases in a Swedish pilot study to prevent occipital flattening in infants (N = 99).
F. Lennartsson had a parallelogram head form at some point. All but 4 of 21 infants with side preference had other warning signs for NSP development. Three showed head tilt, 10 had asymmetric bald spots, 9 had flat spots, and 2 had a parallelogram head form at some point. At 6 months, 1 had side preference and head tilt and was referred to a pediatrician, 3 had asymmetric bald spots, and 5 had some degree of persisting NSP. A parallelogram head form was detected in 4 infants during a visit. The parallelogram head form was gone by the subsequent visit, yet 2 of these infants also had head tilt and side preference. One recovered by 6 months, and the other was referred to a pediatrician for persisting head tilt and side preference. A third infant had side preference and a flattened occipital spot. The flattened spot persisted at 6 months in this infant. The fourth infant was referred to a pediatrician at 4 months but had persisting NSP at 6 months. In summary, Table 3 illustrates a tendency for infants with one high-risk sign to have another and to develop some degree of NSP. The outcomes of the head form for the infant population (N = 99) and the case infant sample (n = 30) are seen in Table 4. (These samples are not mutually exclusive.) In the infant population, only 5 of 59 infants had persisting NSP at 6 months of age in the group in which guidelines were followed as intended. Of the 40 infants in the comparison group, 10 had some degree of persisting NSP at 6 months of age, and there was missing data for one infant who came to the visit but where the assessment was missed. These were rates of 8.5% and 25.6%, respectively. In the case infant sample, only one third had some degree of persisting NSP at 6 months in the group where guidelines were followed as intended, whereas two thirds in the comparison group had persisting NSP at 6 months. Results indicate that nurses were more successful in preventing NSP when the guidelines were followed as intended. The infant population was large enough to do a hypothesis test. The chi-square value was greater than the critical value, and the p value was significant, which indicates that when the guidelines were followed as intended, they had the desired effect and the null hypothesis can be rejected. The probability that nursing actions had the desired effect on the outcome of infant head form at 6 months was moderate in the post hoc power analysis. Following the guidelines as intended—with early and regular assessments, early advice, and advice when infants showed high-risk signs—also had the desired effect in the case infant subgroup. Because this sample was too small, the probability that nursing actions had the desired effect on the outcome of infant's head shape at 6 months was poor in the post hoc power analysis.
Discussion Volunteer nurses were recruited to minimize nonresponse. All the nurses and families who agreed to participate
Testing Guidelines to Prevent NSP: A Swedish Pilot Study 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 and regularity of early infant health care visits. Child health care nurses need more education to help prevent NSP because the problem is prevalent even in Sweden, where infant-adapted pillows are recommended. During the workplace information visits, some of the nurses revealed that they did not know which type of pillow to recommend or where to find the recommendations, emphasizing the need for guidelines. Because all newborns are at risk for NSP, a list of potential risk factors was included in the guidelines to alert nurses of infants who should be followed up more carefully. Fifty-three infants had no highrisk signs of occipital flattening, and it is understandable that nurses did not continue giving advice to all parents each month for the entire 6 months when there was no indication of a problem. Therefore, the decrease in nurse advice illustrated in Figure 1 should not automatically be interpreted as less adequate. The guidelines had several limitations that became apparent through contact with experienced clinicians once the pilot study was underway. Infant time spent on a hard floor, including time spent in a “baby gym” is a risk factor that ought to be clearly stated in the practical suggestions to reduce pressure on the back of the infant's head. Otherwise, parents might not think of this, and the nurse, who is not aware of where the child is placed at home, may not advise against it. Apparently, many infants seem to enjoy the baby gym, and some of them spend considerable time there, whereby the backs of their heads are unintentionally exposed to an unsuitably hard surface. Positioning devices for special support of infants with occipital flattening are available and effective, including the Baby Sleep side pillow and Bumbo Baby Sitter, according to A. Öhman (personal communication, February 20, 2009). These positioning devices should be included in future NSP prevention guidelines because experience has shown that advice is not always enough. The pilot study was conducted to identify problems with design and test the feasibility of incorporating the guidelines into clinical practice to refine methods before planning an intervention study. The pilot study had several design limitations. Inclusion time was short, and only infants born during September and October of 2008 were included. Risk signs of NSP in each of these infants and nursing interventions were only recorded for 6 months. Although the aim of the guidelines is to prevent NSP, 15% of infants still had some degree of NSP present at 6 months. Interventions and follow-up are needed even after 6 months because the infant's head is still malleable. Because the study had no control group, the infants were retrospectively divided into two groups to analyze results. This division
545 was related to the hypothesis that following the guidelines early and regularly will prevent NSP. Among many suspected risk factors, only five were signs that nurses assessed in the study. These are factors that nursing actions can influence. Demographic factors such as gender, prematurity, multiple births, and birth rank are also suspected risk factors, but nurses cannot change these. Demographic factors were not accounted for in the study other than being included in the list of potential risk factors. Some nurses not having time or interest in participating or that information about the study did not reach all the nurses could be the reasons that only 19 of 78 nurses volunteered to participate. Instead of relying on contact nurses, direct information to all the nurses may have helped recruit more volunteers. There was no intention to monitor the nurses' skills, and therefore, it is not known how well each nurse actually understood and followed the guidelines. The inter-assessor reliability was not measured, but the importance of all participating nurses being well informed about all the details became apparent when examining the data sheets. Information needs to be very specific in order for it to be followed as intended, and all participating nurses need to receive the same information in the same form, namely, both precise written information and clear verbal instructions. An opportunity for nurses to ask questions and practice assessment skills should be required before participating in a study. There are assessment scales for plagiocephaly and brachycephaly available on the Internet according to A. Öhman (personal communication, February 20, 2009). These would have helped nurses unfamiliar with cranial assessment and provided some inter-assessor reliability. The checklist needs to be revised so that filling it in is easier and clearer to nurses. Although attendance was good, there were some missing data because several infants were not brought to 1 or more voluntary visits. It was surprising that only 67 of the 98 infants' parents received advice at the first visit, and that some parents received no nursing advice at any visit according to the checklists. Even more surprising, nurses sometimes documented high-risk signs yet did not document advice to the parents at the time when information should have been intensified. This result is interpreted as a combination of several factors including the following: nurses' confusion on how to fill in the checklist, nurses forgetting or not having time to fill in that detail, and/or nurses receiving insufficient information before participating in the study. Data from checklists revealed that the guidelines were not always followed as intended. It was not specifically stated in the guidelines that infants were to be assessed at each monthly visit and that parents should receive advice at the first visit and be counseled whenever high-risk signs of infant occipital flattening were present. All 19 participating nurses received written information. Thirteen participating nurses accepted direct verbal instructions from the research nurse, yet even some of these nurses neglected to record advice. Again, this could have been a failure to fill in the
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Table 3 The Course for Infants With Signs of Asymmetric Bald Spot, Head Tilt, Side Preference, and Parallelogram Head Form and the Occipital Outcome at 6 Months of Age in the Swedish Pilot Study to Prevent Occipital Flattening in Infants Individual Infants Infant's Age in With Following Months When Sign Sign Present Asymmetric bald spot 1 4–6
Co-Existing Signs, Infant's Age in Months
Infant Age in Months When Nursing Advice Occipital Outcome for was Given Infant at 6 Months
Flat spot, 3–6
2–6
2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Head tilt 1 2 3
3–6 4 5 5–6 5–6 4 3 3–6 2 4–5 5–6 2–4 3–5 2 3–4 4–5 4 3–5 3
Side preference, 3 Flat spot, 4 Flat spot, 1–5; side preference, 1–3 Side preference, 2–4 Side preference, 2 Flat spot, 4–5; side preference, 1–4 Flat spot, 3; side preference, 2 – (Missed visit, 3–5) Side preference, 2–3 – Came but not assessed, 6 Side preference, 2–4 – Flat spot, 3–6; side preference, 3–5 Side preference, 2 (Missed visit, 2–3); head tilt, 4 – Flat spot, 4–5
4–6 3–4 1–5 1–6 2 1–5 2–4 3 – 2–3 5 3 1–4, 6 1–6 1–5 1–5 1, 4 1–3 1–3
1–4 1–3 2–3, 5–6
1–6 1–3 1–6
4 5 6 Side preference 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19
3–5 6 4
Side preference, 1–2 (Missed visit, 4–5) Flat, 4–5; parallelogram head form, 4; side preference, 2–3, 5–6; referral, 4 Flat spot, 3–5; referral, 3 – (Missed visit, 2–3) Head tilt, 1–4; parallelogram head form, 2 Asymmetric bald spot, 3–6 (Missed visit, 1); flat spot, 2–6 Flat spot, 1–5; asymmetric bald spot, 5 Asymmetric bald spot, 5–6 Asymmetric bald spot, 5–6 Flat spot, 4–5; asymmetric bald spot, 4 Flat spot, 3; asymmetric bald spot, 3 – – Asymmetric bald spot, 4–5 Asymmetric bald spot, 3–5 Flat spot, 2–6 Flat spot, 4–6; parallel form, 4 – Flat spot, 3–6; asymmetric bald spot, 3–4 Asymmetric bald spot, 4–5 Head tilt, 1–3; flat spot, 6 Head tilt, 2–3, 5–6; flat spot, 4–5; parallelogram head form, 4; referral, 4 Flat spot, 1–2 –
1–6 3–6 2–6 1–5 1–6 2 1–5 2–4 1–4 1 2–3 1–4, 6 1–6 1–6 1–3 1–5 1–5 1–3 –
20 21
2 3 2 1–3 2–4 2 1–4 2 2,4 1 2–3 2–4 1–4 2–5 1–2 3–5 2 3 2–3, 5–6 1–2 3–4
1,3 – 1–4
1–4 1, 3–4
Flat spot, asymmetric bald spot Asymmetric bald spot – – Asymmetric bald spot Asymmetric bald spot – – Asymmetric bald spot – – Asymmetric bald spot Missing data – – Flat spot – – – – – Flat spot Head tilt, side preference, referral – Referral – – Asymmetric bald spot Flat spot – Asymmetric bald spot Asymmetric bald spot – – – – – – Flat spot Flat spot – Flat spot – Flat spot Head tilt, side preference, referral – –
Testing Guidelines to Prevent NSP: A Swedish Pilot Study
547
Table 3 (continued) Individual Infants Infant's Age in With Following Months When Sign Present Sign Parallelogram head form 1 2 2 4 3 4 4
3
Co-Existing Signs, Infant's Age in Months Head tilt, 1–4; side preference, 1–2 Side preference, 2–5; flat spot, 4–6 Head tilt, 2–3, 5–6; side preference, 2–3, 5–6; flat spot, 4–5; referral, 4 Flat spot, 4–6; referral, 4
form properly instead of a failure to give advice. This cannot be sorted out and lowers the reliability of both the method and results. Parental compliance is another factor that was not monitored. Although attendance was recorded, it is not known what advice parents actually received from their nurse, how well parents understood the advice, or how well they followed the advice at home, where the actual prevention work needs to be done on a daily basis. Measuring these factors was outside the scope of the study. Although there may have been some spontaneous recovery, results of the pilot study indicate that the guidelines can be an effective tool for NSP prevention. There were lower incidences of NSP at 6 months of age in the infant population and in the case infant subgroup when nurses followed guidelines as intended. When examining the results of the pilot study, it is important to remember that NSP designates any degree of occipital flattening because dichotomous variables were used. The severity of occipital flattening was not specified in the results. A small occipital flattened spot is not nearly as severe as a parallelogram head form, yet both are referred to as NSP in the study. Many
Infant Age in Months When Nursing Advice Occipital Outcome for was Given Infant at 6 Months – Flat spot Head tilt, side preference, referral Flat spot
1–6 1–6 1–6 1–2
infants referred to as persistent cases at 6 months may very well have had completely acceptable head shapes. Some nurses added the comment “only a little” when documenting presence of a flat spot, yet to be considered a case when there is only a little occipital flattening is somewhat exaggerated. A less strict definition of NSP would give different results.
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 important. Nurses need to intensify the amount of information provided to parents and follow up infants more closely
Table 4 The Relationship Between Nursing Actions and Head Shape Outcome at 6 Months of Age for the Infant Population and for Case Infants (Infants With Some Degree of Occipital Flattening During at Least One Assessment) in the Swedish Pilot Study to Prevent Occipital Flattening From September 1, 2008, Until May 11, 2009 Infant Population (N = 99, Missing Data = 1)
Infants
Case Infants (n = 30)
Group in Which Comparison Group Group in Which Comparison Group in Guidelines Were in Which Guideline Guidelines Were Followed by Nurses Intentions Were Not Followed by Nurses Which Guideline Intentions Were Not Fully Met as Intended Fully Met as Intended
No occipital flattening at age 6 months Some degree of occipital flattening at age 6 months Chi-square test: df = 1 Critical value = 3.841 Post hoc power analysis Note: The samples are not mutually exclusive. ⁎ p b .05.
54 5 χ2 = 5.34 ⁎p = .02 1−β = 61%
29 10
10 5 χ2 = 3.33 p = .068 1−β = 30%
5 10
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when they discover infants that have high vulnerability for NSP development. The pilot study has provided several insights for future design. All nurses need to receive the same information before participating in a study and be well informed about all the details. Written and verbal instructions need to be more precise. The guidelines should be revised with the inclusion of plagiocephaly and brachycephaly assessment scales, several more practical suggestions to reduce pressure on the back of the infant's head, and positioning devices for special support of infants with NSP. Infants should be followed up after 6 months of age to determine long-term outcomes. Finally, the guidelines need to be tested in an intervention study.
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 statistics; Johanna Gilbert in Pennsylvania, USA, for proofreading; and Annsofie Adolfsson, PhD, University of Skövde, for encouragement as supervisor.
Appendix A. Guidelines for nurses in the Swedish pilot study to prevent occipital flattening in infants Prevent flattening of infant heads: Guidelines for child health care nurses. Assess infant cranium. 1. Examine the back of the child's head. Is there a flattened area? If the infant has a lot of hair, palpate instead. Is there a one-sided bald spot? A centered area of baldness is normal.
2. Examine the infant's head from above and look down. Is there a flattened area? Is there flattening towards one side? Does the forehead protrude on that side? Is there ear advancement on that side?
3. Observe the infant's head. Does the head tilt? This is easiest to see when observing from the back. Does the infant always turn his/her head in the same direction? Is it difficult for the infant to turn his/her head in both directions?
These features can be tested by holding a toy in front of the child and moving it in one direction at a time.
Inform parents of the advantages of placing the infant on his/her back during sleep to prevent SIDS combined with information that gives an understanding of the vulnerability of the infant's head shape. Minimize pressure on the back of the infant's head. The infant should use a soft thick pillow the first three to four months for cushioning and support when sleeping on his/her back. The pillow should be placed under both the head and shoulders so the head does not become bent forward. The infant's head should be placed in alternating directions when put to bed, for example, face to the right side one day and to the left side the next day. This pillow can be replaced with a firm, flat pillow. Take the soft thick pillow away when the infant begins to turn over! When awake, the infant should be placed stomach-side down several times daily, and kept under parental supervision. It is advantageous for the infant to get accustomed to “tummy time” early. Start with short periods and increase the time successively. It is important to make tummy time acceptable to the child. Demonstrate correct positioning at the clinic. Avoid situations in which the infant cannot hold his/her head upright. Avoid long periods in an infant car seat, an infant chair, or swing when the infant's head does not get support, otherwise a side preference can quickly develop. Refer to pediatrician if the interventions have not had desired the effect after 2 to 3 months. Refer to pediatrician quickly if torticollis is suspected. Refer to pediatrician without delay if craniosynostosis is suspected. Brief information on infant occipital flattening The back-to-sleep recommendation to prevent sudden infant death syndrome has resulted in a sharp increase of acquired occipital flattening in infants. The flattening may be centered or asymmetrical parietal–occipital flattening. The problem is common in Sweden despite the recommendation that infants sleep on a soft pillow. The probable cause is the supine position in conjunction with other risk factors. The first four months seem to be the critical period for the development of occipital flattening. A persisting skull deformity has several disadvantages for the child. It can lead to facial asymmetry, psychosocial consequences due to a less attractive appearance, and bonding difficulties. Early detection and intervention are best for the child. Simple interventions at early signs of the problem are preferable to the child needing more extensive treatment later. Occipital flattening in infants is a common problem which the informed child health care nurse has an opportunity to help prevent through early assessments and information to parents.
Testing Guidelines to Prevent NSP: A Swedish Pilot Study Potential risk factors: Premature
Born with a flat Always lies supine spot First child Cephalohematoma Lies on a hard mattress Twin Torticollis Always lies with head turned in the same direction Boy Jaw defect Always fed in same position Breech Auricular Has decreased mobility delivery deformity or activity level Delivered with Hip dysplasia Spends a lot of time in a suction car seat or infant chair Parents have low or high educational levels
549 Which pillow should be recommended? The pillow should meet the following criteria: • be thick and soft so that the infant's head sinks down a little, and the sides get support; • have synthetic filling and tolerate a hot wash in the washing machine; • not have stitching through the pillow in which hollows and bunches develop; and • be 38 × 55 cm (15 × 22 inches) for cribs and 28 × 35 cm (11 × 14 inches) for carriages. Buy a sample for the child health care clinic to show parents. Pillow recommendations for newborns—parent information sheet
Suggestions to reduce pressure on the back of the head: Use a soft, thick infant pillow under the infant's head and shoulders during the first three to four months when the child is supine. Place the child's face in alternate directions right from the beginning when it is time to sleep. Encourage tummy time for play when infant is awake. Encourage parents to hold and hug their infant. Encourage the use of a baby carrier/snuggly. Avoid laying infant on his/her back on the floor. Avoid extended periods in an infant car seat and infant chair. Suggestions to reduce pressure on the asymmetric flattened head: Change sides when nursing or bottle-feeding the infant. Captivate the child's interest to look in the opposite direction with activities that interest the child. Place toys or interesting objects on the side opposite the flattened area. Because the child looks toward the door when parents come into the room, change at which end of the crib the infant is placed. How parents can make tummy time more acceptable for infants: Begin early with short periods and increase the time gradually. Place toys in front of the infant. Be on the floor together with the infant. Pick up the infant before the child becomes too upset. Short periods of quality tummy time are preferable to long periods when the child is unhappy. Lay the child on a lounging parent's chest to help the infant get accustomed to tummy time. Placing the infant's elbows close to his/her body gives more support when the child lifts his/her head. It is easier for an infant to lift his/her head if a small rolled cloth is placed under the child's chest at armpit level.
Because it is recommended that infants sleep on their backs, there is a risk that your child will develop a flattened area from pressure on the back of the head. Therefore, we recommend that your infant sleeps with a pillow for the first 3 to 4 months. Until the time your child begins to turn over, place your infant's head on a thick soft infant pillow and alternate the head direction when putting your child to bed. If the edge of the pillow rests directly under the infant's neck, the head may get bent forward. To avoid this, place the pillow under your infant's head and shoulders. Once your child can turn over, take away the pillow or replace it with a thin, flat pillow. The pillow should meet the following criteria: • be thick and soft so that the infant's head sinks down a little, and the sides get support; • have synthetic filling and tolerate a hot wash in the washing machine; • not have stitching through the pillow in which hollows and bunches develop; and • be 38 × 55 cm (15 × 22 inches) for cribs and 28 × 35 cm (11 × 14 inches) for carriages.
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F. Lennartsson
From a developmental viewpoint, place your infant on his/her tummy when the child is awake. Your baby should: • sleep on his/her back, • play on his/her tummy, and • sit up to see the world. (Note. To be concise, the evidence base including references are found in Tables 1 and 2 in the article
“Developing Guidelines for Swedish Child Health Care Nurses to Prevent Non-Synostotic Plagiocephaly: A Literature Study.” Because of copyright laws, the reader is referred to Biggs (2003) and Hummel and Fortado (2005) for diagrams of the cranial forms seen in brachycephaly, parietal–occipital plagiocephaly, and lambdoid synostosis. These diagrams are very useful for illustrating the vertex view of the cranial forms and what is meant by the parallelogram head shape. A more recent photograph of an infant positioned on a pillow is included in the above recommendations for parents instead of the photograph from 2000 used in the pilot study.)
Appendix B. Data registration sheet for child health care nurses in the Swedish pilot study to prevent infant occipital flattening Data registration: Use one sheet for each infant in your district born during September and October of 2008 if the parent agrees to participate in the study. Infant's date of birth: _____________________ I have received information and give permission for my child to participate in the study: _______________________________________________ (Parent's signature) Mark with an x when the infant has come to the monthly visit, whenever the following signs are present and when nursing interventions are made. Health care visit
1 2 3 4 5 6
Flattened spot at the back of the infant's head
One-sided bald spot
Head has a parallelogram form
Head tilts
Infant always turns head in same direction
Gave advice to parent
Made referral to a pediatrician
mo. mo. mo. mo. mo. mo.
The name of the clinic: __________________________ Nurse's signature: ______________________________ Thank you for participating! Name of researcher: Affiliation: Date:
References Bialocerkowski, A., Vladusic, S., & Howell, S. (2005). Conservative interventions for positional plagiocephaly: A systematic review. Developmental Medicine and Child Neurology, 47, 563−570.
Biggs, W. (2003). Diagnosis and management of positional head deformity. American Family Physician, 67, 1953−1956. Hagelin, E., Magnusson, M., & Sundelin, C. (2007). Barnhälsovård [Child health care]. Stockholm: Liber. Hallberg, A., Lindbladh, E., Petersen, K., Råstam, L., & Håkansson, A. (2005). Swedish child heath care in a changing society. Scandinavian Journal of Caring Sciences, 19, 196−203.
Testing Guidelines to Prevent NSP: A Swedish Pilot Study Hockenberry, M., Wilson, D., & Barrera, P. (2006). Implementing Evidence-Based Nursing Practice in a Pediatric Hospital. Pediatric Nursing, 32, 371−377. Hummel, P., & Fortado, D. (2005). Impacting infant head shapes. Advances in Neonatal Care, 5, 329−340. Hutchison, L., Hutchison, L., Thompson, J., & Mitchell, E. (2004). Plagiocephaly and brachycephaly in the first two years of life: A prospective cohort study. Pediatrics, 114, 970−979. Kabbani, H., & Raghuveer, T. (2004). Craniosynostosis. American Family Physician, 69, e1−e7. Available at: http://www.aafp.org/20040615/2863. html. Date accessed: Janurary 25, 2008. Lauritzen, C., & Tarnow, P. (1999). Sned barnskalle? Ställ rätt diagnos i tid! Lägesbetingade skalldeformationer går att undvika [Assymetric skull? Early correct diagnosis is a must! Positional skull deformations can be avoided]. Läkartidningen, 96, 1447−1453. Littlefield, T., Kelly, K., Pomotto, J., & Beals, S. (2002). Multiple-birth infants at higher risk for development of deformational plagiocephaly: II. Is one twin at greater risk? Pediatrics, 109, 19−25. Littlefield, T., Saba, N., & Kelly, K. (2004). On the current incidence of deformational plagiocephaly: An estimation based on prospective registration at a single center. Seminars in Pediatric Neurology, 11, 301−304.
551 Morrison, C., & Chariker, M. (2006). Positional plagiocephaly: Pathogenesis, diagnosis, and management. J Ky Med Assn, 104, 136−140. Persing, J., James, H., Swanson, J., Kattwinkel, J., Committee on Practice and Ambulatory Medicine, Section on Plastic Surgery, & Section on Neurological Surgery. (2003). Prevention and management of positional skull deformities in infants (AAP clinical rapport: Guidance for the clinician in rendering pediatric care). Pediatrics, 112, 199−202. Socialstyrelsen. (2006). Minska risken för plötslig spädbarnsdöd [Decrease the risk of sudden infant death syndrome]. Available at: http://www. socialstyrelsen.se/Publicerat/2006/9337/html2006-114-40.htm. Date accessed: April 1, 2008. Task Force on Sudden Infant Death Syndrome. (2005). The changing concept of sudden infant death syndrome: Diagnostic coding shifts, controversies regarding the sleeping environment, and new variables to consider in reducing risk. Pediatrics, 116, 1245−1255. Öhman, A., & Beckung, E. (2005). Functional and cosmetic status in children treated for congenital muscular torticollis as infants. Advances in Physiotherapy, 7, 135−140. Öhman, A., Nilsson, S., Lagerkvist, A. L., & Beckung, E. (2009). Are infants with torticollis at risk of having delay in achieving early motor milestones compared with a control group of healthy infants? Developmental Medicine and Child Neurology, 51, 545−550.
Testing Guidelines for Child Health Care Nurses to Prevent Nonsynostotic Plagiocephaly: A Swedish Pilot Study1,2 Freda Lennartsson RN, MSN ⁎ Primärvården Skaraborg, Sweden and School of Life Sciences, University of Skövde, Skövde, Sweden
Key words: Infant-adapted pillow; Occipital flattening; Nonsynostotic plagiocephaly; Sudden infant death syndrome
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. © 2011 Elsevier Inc. All rights reserved.
THE NEWBORN'S CRANIUM is thin and soft and can easily become altered from a unilateral head position on a firm surface, resulting in compensatory bulging elsewhere due to the brain's intense growth during the child's first year (Lauritzen & Tarnow, 1999). Nonsynostotic plagiocephaly (NSP) is a condition in which the back of an infant's head becomes altered as the result of external forces applied to the
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. ⁎ Corresponding author: Freda Lennartsson, RN, MSN. E-mail addresses: [email protected], [email protected].
0882-5963/$ – see front matter © 2011 Elsevier Inc. All rights reserved. doi:10.1016/j.pedn.2010.04.005
malleable cranium. This can occur prenatally or postnatally (Littlefield, Saba, & Kelley, 2004) and often progresses to an asymmetric cranium, ear misalignment, and facial asymmetry (Littlefield, Kelly, Pomotto, & Beals, 2002). The first 4 months seem to be the critical period for the development of NSP acquired after birth (Hutchison, Hutchison, Thompson, & Mitchell, 2004). There has been a steady increase in referrals for NSP following the American Academy of Pediatrics' (AAP) recommendation in 1992 of a supine infant sleeping position to prevent sudden infant death syndrome (SIDS), largely because of poor parent education on the risks of prolonged occipital pressure (Morrison & Chariker, 2006). NSP may self-correct as the infant becomes more mobile, but this is not always the case. A noticeable asymmetric face is often considered less attractive, and the psychosocial developmental consequences of uncorrected severe deformities can be significant (Hummel & Fortado, 2005). There is no conclusive evidence regarding which interventions are most effective in reducing NSP, although counterpositioning in conjunction with physiotherapy and/or helmet therapy was identified as a promising trend according to Bialocerkowski, Vladusic, and Howell (2005). This condition is fairly easy to manage when diagnosed early; treatment can become more difficult and complicated with a prolonged course (Morrison & Chariker, 2006). It is important to differentiate NSP from
542 the rare congenital condition lambdoid synostosis, where occipital flattening occurs from the premature fusion of a cranial suture, and surgery is nearly always indicated (Kabbani & Raghuveer, 2004). The Swedish child health care system is voluntary, free of charge, and an integrated part of primary health care. The attendance rate is nearly 100% according to Hallberg, Lindbladh, Petersen, Råstam, and Håkansson (2005), who refer to a Swedish National Report from 1994. Public health or pediatric nurse specialists work in the approximately 3,000 Swedish child health care centers. Once the newborn is discharged from hospital care, these clinical nurse specialists are the primary health care providers until the child is 6 years of age. It is their responsibility to monitor the child's health and development and to support parents in their parental role. During the infant's first 6 months, nurses assess the child at least 9 times according to the program. (Hagelin, Magnusson, & Sundelin, 2007, pp. 39–45). Following national recommendations, Swedish child health care nurses have advised parents since 1992, among other factors, to lay their infant supine while sleeping to prevent SIDS. Although the AAP discourages the use of pillows in the infant's sleeping environment (Persing et al., 2003; Task Force on Sudden Infant Death Syndrome, 2005), the Swedish National Board of Health and Welfare recommends using an infant-adapted pillow for supine sleeping babies until they are 3 to 4 months of age to concurrently prevent NSP. The soft thick pillow is to be taken away when the infant begins to turn over and may be replaced by a firm, flat infant pillow (Socialstyrelsen, The National Board of Health and Welfare, 2006). Placing the infant prone for play is also recommended nationally. Yet, the problem of NSP persists even in Sweden (Öhman & Beckung, 2005; Öhman, Nilsson, Lagerkvist, & Beckung, 2009). The aim of the pilot study was to test effectiveness of nursing guidelines that can be incorporated into the existing Swedish child health care program to prevent NSP while concomitantly following established SIDS preventive measures. The hypothesis is that early and regular nursing assessments and advice given to parents early and when high-risk signs are present will prevent NSP and resolve cases where occipital flattening has already occurred.
Methods 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.
F. Lennartsson
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 guidelines for nurses that could be incorporated into the existing Swedish child health care program (Appendix A).
Participants and Setting To recruit volunteers, child health care contact nurses in Skaraborg were informed about the pilot study in May 2008 and were asked to inform their coworkers. There are 78 public health and/or pediatric nurse specialists working in 27 child health care centers in the Skaraborg area of Sweden (Navet, Skaraborg Primary Care Intranet homepage, personal access, 2008), and 19 of these nurses, working at 7 child health care centers, volunteered to participate. These nurses were all given a copy of the guidelines and were offered a clinical visit for verbal information. Thirteen of the nurses at 5 clinics accepted the offer of verbal information where the guidelines and study were explained; a doll and infant pillow were used to demonstrate correct infant positioning, and nurses were given an opportunity to ask questions. Nurses informed parents with newborns born during September and October of 2008 in their districts about the study. All infants in the respective districts whose parents provided written informed consent were included. There were 99 infants in the study.
Data Collection Nurses filled in a checklist (Appendix B) each time an infant was brought to the monthly visit until the child was 6 months of age. The presence of any observed occipital flattening, a one-sided bald spot, a parallelogram head form, head tilt, and side preference were the recorded signs assessed by nurses. Advice to parents and referral to a pediatrician were the recorded nursing interventions. Assessment scales were not used.
Data Analysis A database was set up. Seven discrete variables were recorded during the infants' six monthly visits. Five variables were nursing assessments. Two of these assessment variables, flattened occipital spot and parallelogram head form, are signs of some degree of NSP. Infants with some degree of NSP during at least one assessment were referred to as cases. Three assessment variables, asymmetric bald spot, head tilt, and side preference, are potential risk factors. These five variables are all signs that should alert the nurse to potential risk for NSP development. Assessed infants observed to have at least one of these five signs were considered infants with high risk for NSP development. The
Testing Guidelines to Prevent NSP: A Swedish Pilot Study Table 1 The Retrospective Infant Groups in the Swedish Pilot Study to Prevent Infant Occipital Flattening From September 1, 2008, Until May 11, 2009
Infants Who Were Exposed to Nursing Actions as Intended 59 infants They were brought to and assessed during each monthly visit Their parents received nursing advice on NSP prevention at the first visit Their parents received nursing advice whenever signs of highrisk for NSP were present
Infants in the Comparison Group Who Were Not Exposed to All Intended Nursing Actions for Some Reason 40 infants One or more visits or assessments were missed Their parents did not receive nursing advice on NSP prevention at the first visit Nursing advice was not documented although a sign of high-risk for NSP was present
final two variables, advice given to parents and referral made to a pediatrician, were nursing interventions. The relationship between nursing interventions, high risk for NSP development, and cases was examined over time. To evaluate the guidelines, infants were divided retrospectively into two groups, the 59 infants who were exposed to nursing actions in which guidelines were followed as intended and a comparison group, where 40 infants were exposed to nursing actions where guideline intentions were not fully met (Table 1). Infants in the group where guidelines were followed as intended were brought to and assessed at each of the six visits, and their parents received advice at the first visit and received advice whenever signs of high risk for NSP were present. In the comparison group, the infants were not assessed regularly for some reason and/or parents did not receive early advice or did not receive advice when their child showed signs of high vulnerability for NSP development. The guidelines were evaluated by comparing outcomes of head shape in relation to nursing actions when the infants were 6 months old. The fewer NSP cases persisting at age 6 months when infants were exposed to nursing actions as intended, the better the indication of the guideline effects. A
543 hypothesis test was performed. The relationship between nursing actions and outcome of infants' head shape at age 6 months was analyzed using the chi-square test for the infant population. Among these infants, case infants were identified. The relationship between nursing actions and outcome of head shape was also analyzed for this subgroup. These samples were not mutually exclusive. P values of .05 or less were considered statistically significant findings. A post hoc power analysis was also performed.
Ethical Considerations and Permission A letter to parents was formulated to explain who was responsible for the collected information and to promise complete confidentiality. The study design was approved by the Medical Head of the Department of Child Health Care in Skaraborg. An ethical advice statement was then obtained from the Regional Ethics Committee in Gothenburg, who interpreted the study to be important for the prevention of both NSP and torticollis. They warned against frightening parents, so inconclusive evidence regarding possible developmental problems was omitted from the study. Written permission was subsequently obtained from the Head of Department at each health care center where participating nurses were employed. Parents of newborns then received both verbal and written information from their child health care nurses that, in addition to the confidentiality assurance, included the study's purpose and an assurance that participation was voluntary and that participants had a right to discontinue without any repercussions. Written informed parental consent was procured before a newborn was included in the study. SIDS prevention work continued as usual throughout the study.
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
Table 2 Nursing Assessments and Interventions During the Pilot Study to Prevent Infant Occipital Flattening From September 1, 2008, Until May 11, 2009, at 7 Child Health Care Clinics in Sweden Nursing Assessment: No. of Infants Presenting High-Risk Signs for Occipital Flattening
Infant Age at Visit (No. of Infants Assessed Flattened Asymmetric Occipital Side at Each Visit. N = 99) Occipital Spot Bald Spot Preference 1 month (n = 95) 2 months (n = 96) 3 months (n = 98) 4 months (n = 96) 5 months (n = 97) 6 months (n = 98)
2 4 16 24 22 15
0 3 8 12 11 6
7 15 12 8 3 1
Head Tilt 2 3 4 3 2 2
Nursing Intervention: No. of Occasions Parallelogram Advice Given Head Form to Parent 0 1 1 2 0 0
67 44 55 41 32 26
Referral to Pediatrician 0 0 1 2 0 3
544 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 present, and to carefully follow these infants, but this was not always the case. Only 67 of 99 infants' parents received advice at the first visit according to checklists, and not all parents were counseled when infants showed high-risk signs for NSP development. The relationships among nursing advice to parents, infants with at least one recorded sign of high risk for NSP development, cases present and referrals made to a pediatrician at each visit are illustrated in Figure 1. At 2 months, when nursing advice decreased, the number of cases began to rise. The number of cases continued to rise and peaked at 4 months, whereas advice decreased from 3 months on. The aim of the guidelines is to prevent NSP, yet 15% of the infants still had some degree of NSP at 6 months of age. Many high-risk infants became cases. Consistent with instructions, five infants were referred to a pediatrician, of whom four were case infants who failed to improve, and the fifth was referred for suspected torticollis when head tilt was detected at 6 months. A pediatrician was consulted twice for one of these infants. Table 3 illustrates tendencies in the course and occipital outcome for infants with the following high-risk signs: an asymmetrical bald spot, head tilt, side preference, and a parallelogram head shape. Twenty infants had an asymmetric bald spot at some point. Fourteen of them presented other high-risk signs either before, in conjunction with, or after hair growth had filled in the spot. Two of these infants had flattened spots at 6 months of age. Six infants had head tilt at some point. Three recovered, 1 had a flat spot at 6 months, and 2 were referred to a pediatrician. Two of the infants with head tilt also showed side preference, 2 had flat spots, and 1
Figure 1 Relationship between nursing interventions, presence of at least one sign of high risk for occipital flattening, and development of cases in a Swedish pilot study to prevent occipital flattening in infants (N = 99).
F. Lennartsson had a parallelogram head form at some point. All but 4 of 21 infants with side preference had other warning signs for NSP development. Three showed head tilt, 10 had asymmetric bald spots, 9 had flat spots, and 2 had a parallelogram head form at some point. At 6 months, 1 had side preference and head tilt and was referred to a pediatrician, 3 had asymmetric bald spots, and 5 had some degree of persisting NSP. A parallelogram head form was detected in 4 infants during a visit. The parallelogram head form was gone by the subsequent visit, yet 2 of these infants also had head tilt and side preference. One recovered by 6 months, and the other was referred to a pediatrician for persisting head tilt and side preference. A third infant had side preference and a flattened occipital spot. The flattened spot persisted at 6 months in this infant. The fourth infant was referred to a pediatrician at 4 months but had persisting NSP at 6 months. In summary, Table 3 illustrates a tendency for infants with one high-risk sign to have another and to develop some degree of NSP. The outcomes of the head form for the infant population (N = 99) and the case infant sample (n = 30) are seen in Table 4. (These samples are not mutually exclusive.) In the infant population, only 5 of 59 infants had persisting NSP at 6 months of age in the group in which guidelines were followed as intended. Of the 40 infants in the comparison group, 10 had some degree of persisting NSP at 6 months of age, and there was missing data for one infant who came to the visit but where the assessment was missed. These were rates of 8.5% and 25.6%, respectively. In the case infant sample, only one third had some degree of persisting NSP at 6 months in the group where guidelines were followed as intended, whereas two thirds in the comparison group had persisting NSP at 6 months. Results indicate that nurses were more successful in preventing NSP when the guidelines were followed as intended. The infant population was large enough to do a hypothesis test. The chi-square value was greater than the critical value, and the p value was significant, which indicates that when the guidelines were followed as intended, they had the desired effect and the null hypothesis can be rejected. The probability that nursing actions had the desired effect on the outcome of infant head form at 6 months was moderate in the post hoc power analysis. Following the guidelines as intended—with early and regular assessments, early advice, and advice when infants showed high-risk signs—also had the desired effect in the case infant subgroup. Because this sample was too small, the probability that nursing actions had the desired effect on the outcome of infant's head shape at 6 months was poor in the post hoc power analysis.
Discussion Volunteer nurses were recruited to minimize nonresponse. All the nurses and families who agreed to participate
Testing Guidelines to Prevent NSP: A Swedish Pilot Study 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 and regularity of early infant health care visits. Child health care nurses need more education to help prevent NSP because the problem is prevalent even in Sweden, where infant-adapted pillows are recommended. During the workplace information visits, some of the nurses revealed that they did not know which type of pillow to recommend or where to find the recommendations, emphasizing the need for guidelines. Because all newborns are at risk for NSP, a list of potential risk factors was included in the guidelines to alert nurses of infants who should be followed up more carefully. Fifty-three infants had no highrisk signs of occipital flattening, and it is understandable that nurses did not continue giving advice to all parents each month for the entire 6 months when there was no indication of a problem. Therefore, the decrease in nurse advice illustrated in Figure 1 should not automatically be interpreted as less adequate. The guidelines had several limitations that became apparent through contact with experienced clinicians once the pilot study was underway. Infant time spent on a hard floor, including time spent in a “baby gym” is a risk factor that ought to be clearly stated in the practical suggestions to reduce pressure on the back of the infant's head. Otherwise, parents might not think of this, and the nurse, who is not aware of where the child is placed at home, may not advise against it. Apparently, many infants seem to enjoy the baby gym, and some of them spend considerable time there, whereby the backs of their heads are unintentionally exposed to an unsuitably hard surface. Positioning devices for special support of infants with occipital flattening are available and effective, including the Baby Sleep side pillow and Bumbo Baby Sitter, according to A. Öhman (personal communication, February 20, 2009). These positioning devices should be included in future NSP prevention guidelines because experience has shown that advice is not always enough. The pilot study was conducted to identify problems with design and test the feasibility of incorporating the guidelines into clinical practice to refine methods before planning an intervention study. The pilot study had several design limitations. Inclusion time was short, and only infants born during September and October of 2008 were included. Risk signs of NSP in each of these infants and nursing interventions were only recorded for 6 months. Although the aim of the guidelines is to prevent NSP, 15% of infants still had some degree of NSP present at 6 months. Interventions and follow-up are needed even after 6 months because the infant's head is still malleable. Because the study had no control group, the infants were retrospectively divided into two groups to analyze results. This division
545 was related to the hypothesis that following the guidelines early and regularly will prevent NSP. Among many suspected risk factors, only five were signs that nurses assessed in the study. These are factors that nursing actions can influence. Demographic factors such as gender, prematurity, multiple births, and birth rank are also suspected risk factors, but nurses cannot change these. Demographic factors were not accounted for in the study other than being included in the list of potential risk factors. Some nurses not having time or interest in participating or that information about the study did not reach all the nurses could be the reasons that only 19 of 78 nurses volunteered to participate. Instead of relying on contact nurses, direct information to all the nurses may have helped recruit more volunteers. There was no intention to monitor the nurses' skills, and therefore, it is not known how well each nurse actually understood and followed the guidelines. The inter-assessor reliability was not measured, but the importance of all participating nurses being well informed about all the details became apparent when examining the data sheets. Information needs to be very specific in order for it to be followed as intended, and all participating nurses need to receive the same information in the same form, namely, both precise written information and clear verbal instructions. An opportunity for nurses to ask questions and practice assessment skills should be required before participating in a study. There are assessment scales for plagiocephaly and brachycephaly available on the Internet according to A. Öhman (personal communication, February 20, 2009). These would have helped nurses unfamiliar with cranial assessment and provided some inter-assessor reliability. The checklist needs to be revised so that filling it in is easier and clearer to nurses. Although attendance was good, there were some missing data because several infants were not brought to 1 or more voluntary visits. It was surprising that only 67 of the 98 infants' parents received advice at the first visit, and that some parents received no nursing advice at any visit according to the checklists. Even more surprising, nurses sometimes documented high-risk signs yet did not document advice to the parents at the time when information should have been intensified. This result is interpreted as a combination of several factors including the following: nurses' confusion on how to fill in the checklist, nurses forgetting or not having time to fill in that detail, and/or nurses receiving insufficient information before participating in the study. Data from checklists revealed that the guidelines were not always followed as intended. It was not specifically stated in the guidelines that infants were to be assessed at each monthly visit and that parents should receive advice at the first visit and be counseled whenever high-risk signs of infant occipital flattening were present. All 19 participating nurses received written information. Thirteen participating nurses accepted direct verbal instructions from the research nurse, yet even some of these nurses neglected to record advice. Again, this could have been a failure to fill in the
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Table 3 The Course for Infants With Signs of Asymmetric Bald Spot, Head Tilt, Side Preference, and Parallelogram Head Form and the Occipital Outcome at 6 Months of Age in the Swedish Pilot Study to Prevent Occipital Flattening in Infants Individual Infants Infant's Age in With Following Months When Sign Sign Present Asymmetric bald spot 1 4–6
Co-Existing Signs, Infant's Age in Months
Infant Age in Months When Nursing Advice Occipital Outcome for was Given Infant at 6 Months
Flat spot, 3–6
2–6
2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Head tilt 1 2 3
3–6 4 5 5–6 5–6 4 3 3–6 2 4–5 5–6 2–4 3–5 2 3–4 4–5 4 3–5 3
Side preference, 3 Flat spot, 4 Flat spot, 1–5; side preference, 1–3 Side preference, 2–4 Side preference, 2 Flat spot, 4–5; side preference, 1–4 Flat spot, 3; side preference, 2 – (Missed visit, 3–5) Side preference, 2–3 – Came but not assessed, 6 Side preference, 2–4 – Flat spot, 3–6; side preference, 3–5 Side preference, 2 (Missed visit, 2–3); head tilt, 4 – Flat spot, 4–5
4–6 3–4 1–5 1–6 2 1–5 2–4 3 – 2–3 5 3 1–4, 6 1–6 1–5 1–5 1, 4 1–3 1–3
1–4 1–3 2–3, 5–6
1–6 1–3 1–6
4 5 6 Side preference 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19
3–5 6 4
Side preference, 1–2 (Missed visit, 4–5) Flat, 4–5; parallelogram head form, 4; side preference, 2–3, 5–6; referral, 4 Flat spot, 3–5; referral, 3 – (Missed visit, 2–3) Head tilt, 1–4; parallelogram head form, 2 Asymmetric bald spot, 3–6 (Missed visit, 1); flat spot, 2–6 Flat spot, 1–5; asymmetric bald spot, 5 Asymmetric bald spot, 5–6 Asymmetric bald spot, 5–6 Flat spot, 4–5; asymmetric bald spot, 4 Flat spot, 3; asymmetric bald spot, 3 – – Asymmetric bald spot, 4–5 Asymmetric bald spot, 3–5 Flat spot, 2–6 Flat spot, 4–6; parallel form, 4 – Flat spot, 3–6; asymmetric bald spot, 3–4 Asymmetric bald spot, 4–5 Head tilt, 1–3; flat spot, 6 Head tilt, 2–3, 5–6; flat spot, 4–5; parallelogram head form, 4; referral, 4 Flat spot, 1–2 –
1–6 3–6 2–6 1–5 1–6 2 1–5 2–4 1–4 1 2–3 1–4, 6 1–6 1–6 1–3 1–5 1–5 1–3 –
20 21
2 3 2 1–3 2–4 2 1–4 2 2,4 1 2–3 2–4 1–4 2–5 1–2 3–5 2 3 2–3, 5–6 1–2 3–4
1,3 – 1–4
1–4 1, 3–4
Flat spot, asymmetric bald spot Asymmetric bald spot – – Asymmetric bald spot Asymmetric bald spot – – Asymmetric bald spot – – Asymmetric bald spot Missing data – – Flat spot – – – – – Flat spot Head tilt, side preference, referral – Referral – – Asymmetric bald spot Flat spot – Asymmetric bald spot Asymmetric bald spot – – – – – – Flat spot Flat spot – Flat spot – Flat spot Head tilt, side preference, referral – –
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Table 3 (continued) Individual Infants Infant's Age in With Following Months When Sign Present Sign Parallelogram head form 1 2 2 4 3 4 4
3
Co-Existing Signs, Infant's Age in Months Head tilt, 1–4; side preference, 1–2 Side preference, 2–5; flat spot, 4–6 Head tilt, 2–3, 5–6; side preference, 2–3, 5–6; flat spot, 4–5; referral, 4 Flat spot, 4–6; referral, 4
form properly instead of a failure to give advice. This cannot be sorted out and lowers the reliability of both the method and results. Parental compliance is another factor that was not monitored. Although attendance was recorded, it is not known what advice parents actually received from their nurse, how well parents understood the advice, or how well they followed the advice at home, where the actual prevention work needs to be done on a daily basis. Measuring these factors was outside the scope of the study. Although there may have been some spontaneous recovery, results of the pilot study indicate that the guidelines can be an effective tool for NSP prevention. There were lower incidences of NSP at 6 months of age in the infant population and in the case infant subgroup when nurses followed guidelines as intended. When examining the results of the pilot study, it is important to remember that NSP designates any degree of occipital flattening because dichotomous variables were used. The severity of occipital flattening was not specified in the results. A small occipital flattened spot is not nearly as severe as a parallelogram head form, yet both are referred to as NSP in the study. Many
Infant Age in Months When Nursing Advice Occipital Outcome for was Given Infant at 6 Months – Flat spot Head tilt, side preference, referral Flat spot
1–6 1–6 1–6 1–2
infants referred to as persistent cases at 6 months may very well have had completely acceptable head shapes. Some nurses added the comment “only a little” when documenting presence of a flat spot, yet to be considered a case when there is only a little occipital flattening is somewhat exaggerated. A less strict definition of NSP would give different results.
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 important. Nurses need to intensify the amount of information provided to parents and follow up infants more closely
Table 4 The Relationship Between Nursing Actions and Head Shape Outcome at 6 Months of Age for the Infant Population and for Case Infants (Infants With Some Degree of Occipital Flattening During at Least One Assessment) in the Swedish Pilot Study to Prevent Occipital Flattening From September 1, 2008, Until May 11, 2009 Infant Population (N = 99, Missing Data = 1)
Infants
Case Infants (n = 30)
Group in Which Comparison Group Group in Which Comparison Group in Guidelines Were in Which Guideline Guidelines Were Followed by Nurses Intentions Were Not Followed by Nurses Which Guideline Intentions Were Not Fully Met as Intended Fully Met as Intended
No occipital flattening at age 6 months Some degree of occipital flattening at age 6 months Chi-square test: df = 1 Critical value = 3.841 Post hoc power analysis Note: The samples are not mutually exclusive. ⁎ p b .05.
54 5 χ2 = 5.34 ⁎p = .02 1−β = 61%
29 10
10 5 χ2 = 3.33 p = .068 1−β = 30%
5 10
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when they discover infants that have high vulnerability for NSP development. The pilot study has provided several insights for future design. All nurses need to receive the same information before participating in a study and be well informed about all the details. Written and verbal instructions need to be more precise. The guidelines should be revised with the inclusion of plagiocephaly and brachycephaly assessment scales, several more practical suggestions to reduce pressure on the back of the infant's head, and positioning devices for special support of infants with NSP. Infants should be followed up after 6 months of age to determine long-term outcomes. Finally, the guidelines need to be tested in an intervention study.
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 statistics; Johanna Gilbert in Pennsylvania, USA, for proofreading; and Annsofie Adolfsson, PhD, University of Skövde, for encouragement as supervisor.
Appendix A. Guidelines for nurses in the Swedish pilot study to prevent occipital flattening in infants Prevent flattening of infant heads: Guidelines for child health care nurses. Assess infant cranium. 1. Examine the back of the child's head. Is there a flattened area? If the infant has a lot of hair, palpate instead. Is there a one-sided bald spot? A centered area of baldness is normal.
2. Examine the infant's head from above and look down. Is there a flattened area? Is there flattening towards one side? Does the forehead protrude on that side? Is there ear advancement on that side?
3. Observe the infant's head. Does the head tilt? This is easiest to see when observing from the back. Does the infant always turn his/her head in the same direction? Is it difficult for the infant to turn his/her head in both directions?
These features can be tested by holding a toy in front of the child and moving it in one direction at a time.
Inform parents of the advantages of placing the infant on his/her back during sleep to prevent SIDS combined with information that gives an understanding of the vulnerability of the infant's head shape. Minimize pressure on the back of the infant's head. The infant should use a soft thick pillow the first three to four months for cushioning and support when sleeping on his/her back. The pillow should be placed under both the head and shoulders so the head does not become bent forward. The infant's head should be placed in alternating directions when put to bed, for example, face to the right side one day and to the left side the next day. This pillow can be replaced with a firm, flat pillow. Take the soft thick pillow away when the infant begins to turn over! When awake, the infant should be placed stomach-side down several times daily, and kept under parental supervision. It is advantageous for the infant to get accustomed to “tummy time” early. Start with short periods and increase the time successively. It is important to make tummy time acceptable to the child. Demonstrate correct positioning at the clinic. Avoid situations in which the infant cannot hold his/her head upright. Avoid long periods in an infant car seat, an infant chair, or swing when the infant's head does not get support, otherwise a side preference can quickly develop. Refer to pediatrician if the interventions have not had desired the effect after 2 to 3 months. Refer to pediatrician quickly if torticollis is suspected. Refer to pediatrician without delay if craniosynostosis is suspected. Brief information on infant occipital flattening The back-to-sleep recommendation to prevent sudden infant death syndrome has resulted in a sharp increase of acquired occipital flattening in infants. The flattening may be centered or asymmetrical parietal–occipital flattening. The problem is common in Sweden despite the recommendation that infants sleep on a soft pillow. The probable cause is the supine position in conjunction with other risk factors. The first four months seem to be the critical period for the development of occipital flattening. A persisting skull deformity has several disadvantages for the child. It can lead to facial asymmetry, psychosocial consequences due to a less attractive appearance, and bonding difficulties. Early detection and intervention are best for the child. Simple interventions at early signs of the problem are preferable to the child needing more extensive treatment later. Occipital flattening in infants is a common problem which the informed child health care nurse has an opportunity to help prevent through early assessments and information to parents.
Testing Guidelines to Prevent NSP: A Swedish Pilot Study Potential risk factors: Premature
Born with a flat Always lies supine spot First child Cephalohematoma Lies on a hard mattress Twin Torticollis Always lies with head turned in the same direction Boy Jaw defect Always fed in same position Breech Auricular Has decreased mobility delivery deformity or activity level Delivered with Hip dysplasia Spends a lot of time in a suction car seat or infant chair Parents have low or high educational levels
549 Which pillow should be recommended? The pillow should meet the following criteria: • be thick and soft so that the infant's head sinks down a little, and the sides get support; • have synthetic filling and tolerate a hot wash in the washing machine; • not have stitching through the pillow in which hollows and bunches develop; and • be 38 × 55 cm (15 × 22 inches) for cribs and 28 × 35 cm (11 × 14 inches) for carriages. Buy a sample for the child health care clinic to show parents. Pillow recommendations for newborns—parent information sheet
Suggestions to reduce pressure on the back of the head: Use a soft, thick infant pillow under the infant's head and shoulders during the first three to four months when the child is supine. Place the child's face in alternate directions right from the beginning when it is time to sleep. Encourage tummy time for play when infant is awake. Encourage parents to hold and hug their infant. Encourage the use of a baby carrier/snuggly. Avoid laying infant on his/her back on the floor. Avoid extended periods in an infant car seat and infant chair. Suggestions to reduce pressure on the asymmetric flattened head: Change sides when nursing or bottle-feeding the infant. Captivate the child's interest to look in the opposite direction with activities that interest the child. Place toys or interesting objects on the side opposite the flattened area. Because the child looks toward the door when parents come into the room, change at which end of the crib the infant is placed. How parents can make tummy time more acceptable for infants: Begin early with short periods and increase the time gradually. Place toys in front of the infant. Be on the floor together with the infant. Pick up the infant before the child becomes too upset. Short periods of quality tummy time are preferable to long periods when the child is unhappy. Lay the child on a lounging parent's chest to help the infant get accustomed to tummy time. Placing the infant's elbows close to his/her body gives more support when the child lifts his/her head. It is easier for an infant to lift his/her head if a small rolled cloth is placed under the child's chest at armpit level.
Because it is recommended that infants sleep on their backs, there is a risk that your child will develop a flattened area from pressure on the back of the head. Therefore, we recommend that your infant sleeps with a pillow for the first 3 to 4 months. Until the time your child begins to turn over, place your infant's head on a thick soft infant pillow and alternate the head direction when putting your child to bed. If the edge of the pillow rests directly under the infant's neck, the head may get bent forward. To avoid this, place the pillow under your infant's head and shoulders. Once your child can turn over, take away the pillow or replace it with a thin, flat pillow. The pillow should meet the following criteria: • be thick and soft so that the infant's head sinks down a little, and the sides get support; • have synthetic filling and tolerate a hot wash in the washing machine; • not have stitching through the pillow in which hollows and bunches develop; and • be 38 × 55 cm (15 × 22 inches) for cribs and 28 × 35 cm (11 × 14 inches) for carriages.
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From a developmental viewpoint, place your infant on his/her tummy when the child is awake. Your baby should: • sleep on his/her back, • play on his/her tummy, and • sit up to see the world. (Note. To be concise, the evidence base including references are found in Tables 1 and 2 in the article
“Developing Guidelines for Swedish Child Health Care Nurses to Prevent Non-Synostotic Plagiocephaly: A Literature Study.” Because of copyright laws, the reader is referred to Biggs (2003) and Hummel and Fortado (2005) for diagrams of the cranial forms seen in brachycephaly, parietal–occipital plagiocephaly, and lambdoid synostosis. These diagrams are very useful for illustrating the vertex view of the cranial forms and what is meant by the parallelogram head shape. A more recent photograph of an infant positioned on a pillow is included in the above recommendations for parents instead of the photograph from 2000 used in the pilot study.)
Appendix B. Data registration sheet for child health care nurses in the Swedish pilot study to prevent infant occipital flattening Data registration: Use one sheet for each infant in your district born during September and October of 2008 if the parent agrees to participate in the study. Infant's date of birth: _____________________ I have received information and give permission for my child to participate in the study: _______________________________________________ (Parent's signature) Mark with an x when the infant has come to the monthly visit, whenever the following signs are present and when nursing interventions are made. Health care visit
1 2 3 4 5 6
Flattened spot at the back of the infant's head
One-sided bald spot
Head has a parallelogram form
Head tilts
Infant always turns head in same direction
Gave advice to parent
Made referral to a pediatrician
mo. mo. mo. mo. mo. mo.
The name of the clinic: __________________________ Nurse's signature: ______________________________ Thank you for participating! Name of researcher: Affiliation: Date:
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551 Morrison, C., & Chariker, M. (2006). Positional plagiocephaly: Pathogenesis, diagnosis, and management. J Ky Med Assn, 104, 136−140. Persing, J., James, H., Swanson, J., Kattwinkel, J., Committee on Practice and Ambulatory Medicine, Section on Plastic Surgery, & Section on Neurological Surgery. (2003). Prevention and management of positional skull deformities in infants (AAP clinical rapport: Guidance for the clinician in rendering pediatric care). Pediatrics, 112, 199−202. Socialstyrelsen. (2006). Minska risken för plötslig spädbarnsdöd [Decrease the risk of sudden infant death syndrome]. Available at: http://www. socialstyrelsen.se/Publicerat/2006/9337/html2006-114-40.htm. Date accessed: April 1, 2008. Task Force on Sudden Infant Death Syndrome. (2005). The changing concept of sudden infant death syndrome: Diagnostic coding shifts, controversies regarding the sleeping environment, and new variables to consider in reducing risk. Pediatrics, 116, 1245−1255. Öhman, A., & Beckung, E. (2005). Functional and cosmetic status in children treated for congenital muscular torticollis as infants. Advances in Physiotherapy, 7, 135−140. Öhman, A., Nilsson, S., Lagerkvist, A. L., & Beckung, E. (2009). Are infants with torticollis at risk of having delay in achieving early motor milestones compared with a control group of healthy infants? Developmental Medicine and Child Neurology, 51, 545−550.