by Olga Maystruk, Designer and Brand Strategist; and
Emma Louise, Risk Management Representative
On July 16, 2012, a woman brought her 10-month-old son to Pediatrician A’s office for evaluation of reported head asymmetry and earache. Pediatrician A had been the patient’s treating physician for several routine well-child visits since birth.
During the physical exam, it was documented that the patient was well developed, well nourished, and had a normal appearance. There was no ear shift and there was only a slight right flattening of the baby’s occiput. The physician diagnosed the patient with an allergy and a slight plagiocephaly. The physician advised the mother that head asymmetry due to positioning often disappears with age.
During the next six-month period, Pediatrician A saw the patient six times for well checks. According to the records, no further discussion of the patient’s head shape occurred.
On April 8, 2013, when the patient was 19 months old, the mother took him to a plagiocephaly specialist where the patient was diagnosed with significant plagiocephaly. The mother was informed that it was too late for head banding. She then made a distressed phone call to Pediatrician A who apologized for perhaps not treating the patient more aggressively. Pediatrician A offered to help her find another pediatrician and recommended an evaluation by a cranial surgeon.
One week later, the mother took her son to Pediatrician B’s office, who noted cranial asymmetry and mild facial asymmetry.
The patient saw Pediatrician B six more times for well checks over the next two years. Medical records indicated no skull molding during two of those visits. No other issues or head shape discussions were noted.
Additionally, the patient was seen by a cranial surgeon who advised against surgical intervention because the plagiocephaly was not life threatening and it was not affecting the patient’s face. The surgeon noted that the condition is not likely to get worse or improve significantly with time.
A lawsuit was filed against Pediatrician A. Allegations included failure to:
- provide adequate medical treatment;
- assess and evaluate the patient adequately; and
- refer to a specialist.
Expert consultants for the defense were mostly supportive of Pediatrician A’s general course of treatment. However, the consultants noted a possible deviation from the standard of care due to Pediatrician A not diagnosing plagiocephaly until the patient was 10 months old. Had the physician noted head asymmetry sooner, the patient may have been referred to a specialist for cranial molding orthosis therapy.
Additionally, the various consultants considered the actual severity of the patient’s head asymmetry and the effectiveness of potential treatments. The differing opinions illustrated the difficulty in predicting the outcome of the case.
The plaintiff’s consultant stated Pediatrician A breached the standard of care by failing to recognize the “persistence, progression, and/or severity” of the patient’s plagiocephaly over several office visits. The consultant also criticized Pediatrician A for not adequately documenting his treatment for the patient (repositioning) at the July 16 visit, and the patient’s progress with treatment over the next six visits.
The case was settled on behalf of Pediatrician A.
Risk management considerations
A significant weakness in this case was the lack of documentation regarding the plagiocephaly diagnosis. Pediatrician A identified plagiocephaly at the patient’s 10-month appointment and documented his intention to “watch” and recheck at the next well check. However, the patient was seen at 11 months and again at the 12-month well check and there was no documentation to suggest monitoring took place.
According to the American Academy of Pediatrics, promoting optimal development includes continued screening and surveillance throughout childhood. “Medical records should document the outcome of all surveillance and screening activities during preventive care visits. Additionally, specific actions taken or planned, such as scheduling an early follow-up visit, scheduling a visit to discuss developmental concerns more fully, or referrals to medical specialists or early childhood programs and specialists, also should be noted as part of developmental surveillance and screening.” 1
Two types of plagiocephaly may be identified with physical examination, and a diagnosis confirmed through further testing such as diagnostic imaging and genetic testing. 2 “Accurate diagnosis and treatment of infants with positional plagiocephaly are important because it is a common finding seen by multiple pediatric specialties, including general pediatricians, neurosurgeons, neurologists, plastic surgeons, and physical therapists.” 3
Consultants in this case were critical of the physician for knowing the progression of plagiocephaly, yet not providing appropriate treatment including referring the patient to a specialist, physical therapy, or implementing helmeting. The physician did not document his reasoning for the continued monitoring of the patient without a treatment plan. This lack of documentation placed the physician at risk for a medical liability claim.
Guidelines for acceptable and adequate medical documentation emphasize the importance of complete, current, consistent, and legible records. The Texas Medical Board specifies that the written treatment plan should include any referrals and consultations, patient/family education, and specific instructions for follow-up. 4
The defensibility of this case may have been improved had the physician fully and accurately documented his rationale regarding monitoring the patient, education of the family, and consideration of treatment options.
1 Lipkin PH, Macias MM, et. al. Promoting Optimal Development Identifying Infants and Young Children With Developmental Disorders Through Developmental Surveillance and Screening. American Academy of Pediatrics. Clinical Report. January 2, 2020. Available at a https://publications.aap.org/pediatrics/article/145/1/e20193449/36971/Promoting-Optimal-Development-Identifying-Infants?searchresult=1. Accessed March 28, 2023.
2 Pediatric plagiocephaly. Children's National Hospital. Available at https://childrensnational.org/visit/conditions-and-treatments/genetic-disorders-and-birth-defects/plagiocephaly#:~:text=If%20congenital%20plagiocephaly%2C%20which%20is,Seizures. Accessed March 28, 2023.
3 Flannery AM, Tamber S, et. al. Congress of Neurological Surgeons Systematic Review and Evidence-Based Guidelines for the Management of Patients with Positional Plagiocephaly. Neurosurgery. November 2016. Available at https://journals.lww.com/neurosurgery/Fulltext/2016/11000/Congress_of_Neurological_Surgeons_Systematic.1.aspx. Accessed March 28, 2023.
4 Texas Administrative Code. Title 22, Part 9, Chapter 165.1(4)(5)(6)(B)(C)(D). Available at at https://texreg.sos.state.tx.us/public/readtac$ext.TacPage?sl=R&app=9&p_dir=&p_rloc=&p_tloc=&p_ploc=&pg=1&p_tac=&ti=22&pt=9&ch=165&rl=1. Accessed March 28, 2023.
Olga Maystruk can be reached at firstname.lastname@example.org.
Emma Louise can be reached at email@example.com.