Two Steps Forward, One Step Back
In pediatrics medicine, we continuously strive to make kids healthier. But sometimes to improve one problem we inadvertently create another, as demonstrated by the American Academy of Pediatrics’ “Back to Sleep Campaign”.
Launched in 1992, the Back to Sleep Campaign has been a true success story, reducing the incidence of SIDS (Sudden Infant Death Syndrome) by nearly 50%! The untoward consequence of the program, however, was a marked increase in flattening along the back of the head. While this problem is not life-threatening, like SIDS, it has become a source of anxiety to parents of affected infants. And, there is a lot of misinformation and confusion about what flat heads are really about and how, if at all, they should be addressed.
Ryan’s Story: A Common Tale
Ryan is a 6 month old baby boy from the North East United States who was placed on his back to sleep since birth. As he got bigger, his parents noticed a flattening develop on the right side of the back of his head which was very pronounced by 3 months of age. Concerned, they consulted Ryan’s pediatrician who diagnosed Ryan with “positional plagiocephaly” and advised repositioning techniques, such as putting him down on different ends of the crib so his head will get used to turning in both directions.
Ryan’s parents attempted the repositioning for a month but saw little, if any, improvement. They were also nervous to try this for too long fearing they’d lose their window for a helmet to be most effective. To explore options, they consulted the large orthotic group in their area which was willing to make Ryan a helmet but they faced two hurdles. First, their insurance would not pay for the helmet, as this was a “cosmetic” problem. Second, the specialists were not convincing that the helmet was truly needed.
As their quest for information continued, Ryan’s head began to appear more round, not just to their eyes but to Ryan’s pediatrician and nurse practitioner as well. So, with Ryan now 5 months old and moving around well in his crib, they opted to let nature take its course.
Ryan’s story has a happy ending but was it luck or something more?
Flat Heads: A Historical Perspective
Posterior head flattening, termed plagiocephaly (Greek “oblique head”) if it is asymmetric (only on one side), or brachycephaly (Greek “short head”) if it is symmetric (entire back flat), is not a new problem and has been in existence since ancient times. Many modern cultures, such as China and India, have practiced back sleeping for centuries. In these countries, moderate flattening is ubiquitous, well recognized, and more readily accepted.
In our country, however, flat infant heads are a relatively new phenomenon that we are not yet acclimated to. As a result, overwhelming attention has been focused on the diagnosis, prevention, and treatment of this deformity giving rise to an industry of unproven commercial devices and services that claim to treat or prevent the condition. Many simply don’t work, such as pillows and wedges, while others seem to work if initiated early enough such as the popular infant head helmets and bands, and the very new infant head cup, which is the only truly preventative modality available.
What is reassuring is that development and brain growth are not impacted by the myriad of head shapes that are developing with the Back to Sleep campaign. And, with more babies developing positional deformities, our definition of “normal” may be slowly changing.
A Postnatal Problem with a Prenatal Start
With the majority of babies sleeping on their backs, it is easy to imagine a future world of flat headed people. But, that is not the case at all. “Not every infant who lies on the back gets flat, and in fact, only about 20% actually develop clinically significant flattening”, notes Dr. Gary Rogers, plastic surgeon specializing in head shape abnormalities at the Children’s Hospital Boston.
According to Dr. Rogers, the problem starts before birth. If the baby’s head movement is restricted in utero, he or she may develop contracture of the neck muscles (torticollis). Like any muscle group, the neck muscles can become tight if they are not allowed to move freely. Once born, the tight neck will keep the infant’s head in a similar position to what it experienced while in mom’s womb. Other well established risk factors for plagiocephaly include: multiple births (e.g. twins), breech position, first born babies, male babies, low fluid in the uterus, and prematurity. It is no surprise that these are also risk factors for torticollis or neck muscle imbalance.
Once an infant is born, the head grows against a flat surface (bed, car seat, etc.). This is similar to a pumpkin growing in a field. If the pumpkin is not rotated during growth, it will become progressively flattened on the down side. But if the pumpkin is turned intermittently, the pumpkin will remain round. This is the same for infants with poor neck mobility. If unable to move the head to both sides, their heads will become flatter as the head rapidly grows during the first few months of life. After 4 months, most infants, even those with tight neck muscles, have sufficient strength and neurologic development to reposition their head and the flattening usually stops getting worse.
What happens after this point has been a source of confusion for parents and physicians. There is little evidence to suggest that the flattening ever “pops out”. Whatever degree of flattening developed early on will persist but will look less pronounced as the head gets bigger. “The improvement is relative to the increase in head size. Additionally, hair growth can act to camouflage flattening”, explains Dr. Rogers. “It is analogous to comparing a one centimeter indentation in an apple (the 6 months old) vs. the same dent in a watermelon (the older child). The dent looks much less impressive on the later fruit, even though the actual size and depth of the indentation is identical.”
Diagnosing positional deformities is purely clinical. Radiographic studies are reserved for the very few times the head shape falls out of the range of what is expected from a baby sleeping on the back. And, even then, 99.9% turn out to be deformational. The remaining 0.1% are from a premature fusion of the posterior cranial sutures, called craniosynostosis. While those situations do require further testing and surgery to correct, a baby can safely be diagnosed well into their first year of life. So, while specialists like Dr. Rogers are helpful for the few and rare cases of flat heads that are not typical, this is clearly a situation that can be handled by most pediatricians.
Beauty is in the eye of the beholder.
The Chinese still use swaddle boards to carry babies while they work. This results in the characteristic head shape of this culture. That is what their culture strives for.
In our culture, head shape is much more individual. This is truly a case where beauty is in the eye of the beholder. As long as you are comfortable with how your baby looks, whatever treatment you decide will be the right one.
(Acknowledgments: Dr. Gwenn would like to thank Dr. Gary Rogers from Children’s Hospital Boston for his time, input and contributions to this article, as well as for images from his picture collection.)
TYPES OF ORTHOTICS
Non-helmet Orthotic Devices and Resting Surface Alterations
Examples: memory foam, contoured pillows, cut-out surfaces, and slings.
What they claim to do: decrease focal pressure by increasing the area of contact with the supine infant’s occipital (the back of the head).
Why they don’t work: They do not expand to accommodate rapid head growth during infancy and do not provide for variable skull size. Soft or moldable surfaces, such as memory foam, are ineffective because the infant’s head, which weighs about 1 pound, cannot deform the surface into a concave, anatomically normal shape.
What they claim to do: they are intended to vary the point of contact between the surface and the infant’s occipital.
Why they don’t work: Most wedges only reposition the infant’s body, and many not change the head position at all. They also require constant adjustments by the parents who may be reluctant to continually awaken their sleeping infant. They are also relatively ineffective after about 4 months of age because most infants are mobile by this age and can easily slide off the wedge.
Molding helmets and headbands (cranial orthoses)
Background: described by Clarren and colleagues in 1981 (yes, flattening was treated well before 1992). Clarren founded the concept of helmet therapy on a simple premise: “If the pressure of a rapidly growing brain against a flat surface would flatten the skull, then pressure against a concave surface should round it back again.”
Do they work? Clarren and colleagues demonstrated improved cranial symmetry in all children treated with a helmet, but only 40% improvement when treatment was declined. There have been numerous subsequent reports that verify the effectiveness of helmet orthotics in managing deformational plagiocephaly.
What they claim to do: Developed by Dr. Rogers, these are concave cups that babies sleep in from birth to prevent flattening.
Do they work? Yes.
Downside: they need to be adjusted frequently by a licensed orthotist to allow for head growth.
How long are they needed? Once the baby rolls out of them they are not needed! This is a relatively new treatment and one that can be utilized well before there is a problem. And, it eliminates the development of the flattening to begin with.
BACK TO SLEEP Campaign
(Originally posted March 2007; Updated December 2009)