title: Effectiveness and safety of independent pediatric nurse practitioners in evaluating plagiocephaly.
abstract: BACKGROUND
  The American Academy of Pediatrics Back to Sleep program in 1992 dramatically increased the incidence of posterior plagiocephaly in infants. In 2000, the craniofacial disorders program at Oregon Health & Science University established a plagiocephaly screening clinic staffed by pediatric nurse practitioners.
  
  
  METHODS
  Electronic medical records of patients seen in a single accredited craniofacial disorders clinic from 2005 to 2011 were reviewed retrospectively to identify patients screened independently by pediatric nurse practitioners for positional plagiocephaly versus synostosis.
  
  
  RESULTS
  Over a 7-year period, 1228 patients were independently screened. Over half [638 patients (52 percent)] were followed through subsequent visits for craniofacial disorders without any direct surgeon input. Of these, 169 (26 percent) were treated with orthotic consultation for a molding helmet, 385 (60 percent) received a combination of counseling and/or physical therapy for torticollis, and 84 (13 percent) were lost to follow-up. No patient managed by pediatric nurse practitioners was identified to have cranial synostosis and no patient underwent early or delayed surgery. All returning patients [n=554 (86 percent)] showed improvement in, or resolution of, their presenting deformity. The remaining 590 patients (48 percent) were referred by the pediatric nurse practitioner for surgical consultation. Computed tomographic imaging revealed synostosis in 121 patients.
  
  
  CONCLUSIONS
  Pediatric nurse practitioners accurately screened over half of patients referred to a high-volume craniofacial disorders program for positional plagiocephaly versus synostosis, without surgeon input. Based on available information, no synostosis diagnosis was overlooked using this approach. With specific training, pediatric nurse practitioners working in a craniofacial disorders program can safely and independently screen for positional versus synostotic plagiocephaly.
  
  
  METHODS
  Diagnostic, III.
authors.affiliation: Portland, Ore. From the Department of Surgery, Division of Plastic and Reconstructive Surgery, Child Development and Rehabilitation Center, and Department of Neurological Surgery, Oregon Health & Science University.
authors.forename: Anna A
authors.initials: AA
authors.lastname: Kuang
authors.forename: Curtis
authors.initials: C
authors.lastname: Bergquist
authors.forename: Lisa
authors.initials: L
authors.lastname: Crupi
authors.forename: Maureen
authors.initials: M
authors.lastname: Oliverio
authors.forename: Nathan R
authors.initials: NR
authors.lastname: Selden
mesh_terms: D002675:Child, Preschool; D002983:Clinical Competence; D003398:Craniosynostoses / Q000175:diagnosis / Q000451:nursing* / Q000628:therapy; D016208:Databases, Factual; D005260:Female; D006260:Head Protective Devices; D006801:Humans; D007223:Infant; D008297:Male; D008403:Mass Screening / Q000379:methods / Q000451:nursing; D009722:Nurse Practitioners; D009733:Nursing Diagnosis / Q000379:methods*; D009922:Oregon; D061214:Patient Safety; D010371:Pediatric Nursing / Q000379:methods*; D049068:Plagiocephaly, Nonsynostotic / Q000175:diagnosis / Q000451:nursing* / Q000628:therapy; D011859:Radiography; D012017:Referral and Consultation / Q000706:statistics & numerical data; D012189:Retrospective Studies; D018570:Risk Assessment; D012886:Skull / Q000000981:diagnostic imaging / Q000601:surgery
references.citation: Kane AA, Mitchell LE, Craven KP, Marsh JL. Observations on a recent increase in plagiocephaly without synostosis. Pediatrics. 1996;97:877–885
references.citation: Argenta LC, David LR, Wilson JA, Bell WO. An increase in infant cranial deformity with supine sleeping position. J Craniofac Surg. 1996;7:5–11
references.citation: Habal MB. The new culture of flat heads: A global phenomenon or a local variance. J Craniofac Surg. 2002;13:193–195
references.citation: Teichgraeber JF, Ault JK, Baumgartner J, et al. Deformational posterior plagiocephaly: Diagnosis and treatment. Cleft Palate Craniofac J. 2002;39:582–586
references.citation: Kelly KM, Littlefield TR, Pomatto JK, Manwaring KH, Beals SP. Cranial growth unrestricted during treatment of deformational plagiocephaly. Pediatr Neurosurg. 1999;30:193–199
references.citation: Kelly KM, Littlefield TR, Pomatto JK, Ripley CE, Beals SP, Joganic EF. Importance of early recognition and treatment of deformational plagiocephaly with orthotic cranioplasty. Cleft Palate Craniofac J. 1999;36:127–130
references.citation: Teichgraeber JF, Seymour-Dempsey K, Baumgartner JE, Xia JJ, Waller AL, Gateno J. Molding helmet therapy in the treatment of brachycephaly and plagiocephaly. J Craniofac Surg. 2004;15:118–123
references.citation: Habal MB, Leimkuehler T, Chambers C, Scheuerle J, Guilford AM. Avoiding the sequela associated with deformational plagiocephaly. J Craniofac Surg. 2003;14:430–437
references.citation: Graham JM Jr, Gomez M, Halberg A, et al. Management of deformational plagiocephaly: Repositioning versus orthotic therapy. J Pediatr. 2005;146:258–262
references.citation: Agrawal D, Steinbok P, Cochrane DD. Significance of beaten copper appearance on skull radiographs in children with isolated sagittal synostosis. Childs Nerv Syst. 2007;23:1467–1470
references.citation: Bialocerkowski AE, Vladusic SL, Wei Ng C. Prevalence, risk factors, and natural history of positional plagiocephaly: A systematic review. Dev Med Child Neurol. 2008;50:577–586
references.citation: Blount JP, Louis RG Jr, Tubbs RS, Grant JH. Pansynostosis: A review. Childs Nerv Syst. 2007;23:1103–1109
references.citation: Kapp-Simon KA, Speltz ML, Cunningham ML, Patel PK, Tomita T. Neurodevelopment of children with single suture craniosynostosis: A review. Childs Nerv Syst. 2007;23:269–281
references.citation: Renier D, Sainte-Rose C, Marchac D, Hirsch JF. Intracranial pressure in craniostenosis. J Neurosurg. 1982;57:370–377
references.citation: Tamburrini G, Caldarelli M, Massimi L, Santini P, Di Rocco C. Intracranial pressure monitoring in children with single suture and complex craniosynostosis: A review. Childs Nerv Syst. 2005;21:913–921
references.citation: Glasgow TS, Siddiqi F, Hoff C, Young PC. Deformational plagiocephaly: Development of an objective measure and determination of its prevalence in primary care. J Craniofac Surg. 2007;18:85–92
references.citation: Didier RA, Kuang AA, Schwartz DL, Selden NR, Stevens DM, Bardo DM. Decreasing the effective radiation dose in pediatric craniofacial CT by changing head position. Pediatr Radiol. 2010;40:1910–1917
references.citation: Vance R. The healing of linear fractures of the skull. Am J Roentgenol Radium Ther. 1936;36:744–746
references.citation: Gross RJ. Roentgenologic aspects of head trauma. Am J Roentgenol Radium Ther. 1950;64:399–408
references.citation: Bredero-Boelhouwer H, Treharne LJ, Mathijssen IM. A triage system for referrals of pediatric skull deformities. J Craniofac Surg. 2009;20:242–245