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Sunday, October 30, 2016

Flat heads in babies - What's the best treatment?

Babies often get misshapen heads from laying on one side or even from being squished while still inside mom. The misshaped head is referred to as plagiocephaly, scaphocephaly, or brachycephaly -- depending on the overall shape (see lower photo below). These, especially plagiocephaly, are very common. If I knew I'd one day have a blog, I would have taken pictures showing the head shape of my child who had positional plagiocephaly. That baby is now a teen with a normal head shape, so it's too late for photos. 

Below is a picture of a baby with positional plagiocephaly. Note the flat left back of the head. In this picture you can't see the ears, but we look to see if the ear and forehead are pushed forward to help assess the severity of the plagiocephaly. 

Photosource: By Gzzz via Wikimedia Commons


The Joint Section on Pediatric Neurosurgery of the American Association of Neurological Surgeons and the Congress of Neurological Surgeons have issued new guidelines for diagnosis of as well as treatment options for plagiocephaly with repositioning, physical therapy and helmets.

Diagnosis:


Most of the time we can make the diagnosis in the office without any special tests or x-rays. If there is a concern that one of the sutures (growth plates between the bones of the skull) is closed, a skull x-ray or an ultrasound of the area in question can assess if the suture is open or closed. If the diagnosis is still in question after those studies, a CT of the head may be needed. The picture below shows how the skull shape changes if one or more of the sutures is closed (represented by a missing line).
Photo source:By Xxjamesxx, via Wikimedia Commons Wikimedia

Treatments:

The first treatment used to treat plagiocephaly is repositioning. Repositioning helps with all infants with positional plagiocephaly to some extent. Repositioning is just what it sounds like: change the position of your baby so the side down alternates when sleeping or laying. Put fun items to look at on alternating sides when baby is laying on the back when awake. When feeding, hold baby in alternate arms so when they turn to face you they are looking different directions each feed. (This happens naturally when breastfeeding.) Use supervised tummy time several times each day and hold baby upright as much as possible to get baby off the back of his head when not sleeping. The American Academy of Pediatrics has issued a warning against the use of positioning pillows due to risk of suffocation.  

A stiff neck often is associated with positional plagiocephaly because it limits head movement to one side. The stiff neck is called torticollis. Torticollis makes it difficult for baby to turn his head to one side, but gentle stretching can help. I show parents how to hold one shoulder down while gently moving the head to stretch the neck - with each ear to the shoulder and then the chin to each shoulder. It's important to do a gentle but firm stretch, no jerking or forced movements. Massaging the neck muscles first can help. Think of what you do when you have a sore neck and want to stretch it. Working with a Physical Therapist has been shown to be more effective than repositioning alone and as effective as positioning devices (which are not recommended due to safety concerns).

Babies with persistent moderate to severe plagiocephaly after repositioning and physical therapy may benefit from a helmet to mold the head to a round shape. The helmet corrects more rapidly than positioning alone, so is also used if there is significant plagiocephaly in older infants. I reserve this option for the more severe cases that don't respond to repositioning and physical therapy since it is expensive and often not covered by insurance. I do not know if these recommendations will make it easier for insurance to pay for a helmet when indicated.




Saturday, October 15, 2016

Great News About the HPV Vaccine!

The HPV vaccine has been a controversial vaccine on social media, but anyone who knows me knows that I agree with the recommendations and wholeheartedly endorse it for the reasons given in my favorite HPV Vaccine article.

Photo Source: Jan Christian via Wikimedia

To add to the confusion and misinformation that circulates regarding the safety of the vaccine (which I don't have room to go into here, but is discussed herehere, here, and visually here), the vaccine itself has changed (covering 9 strains now compared to the initial 4 strains) and the dosing schedule is changing.

Don't presume the change in vaccine schedule is to answer the calls of the anti-HPV vaccine crowd. That isn't needed because their claims have been debunked (see all the articles referenced above).


Dosing schedule ~ Happy News!


HPV vaccines were initially approved to be administered as a 3-dose series: dose #2 given two months after the first and the 3rd dose at least 4 months after the second. Giving doses later is acceptable, but they cannot be given too early.

There is research that supports giving just two doses at least 6 months apartA two dose schedule was approved earlier in Europe and this week was approved by the FDA in the US for children 9 to 14 years of age. The two doses should be given 6-12 months apart, which means for most kids they can get the vaccine at two regularly scheduled well visits (such as the 11 year exam and the 12 year exam) and not have to come in for additional visits.

The data support continuing a 3 dose series in those 15 years and up. This means they can get the 2nd dose 2 months after the 1st dose and then a 3rd dose at least 4 months after the 2nd dose and 6 months after the 1st dose.

The official ACIP Meeting Information is not yet available, but will be posed within 90 days of the October 19-20 meeting. (Note: I originally stated this was an October 11 meeting.)

I know that the two dose series will make many kids happy ~ one less shot for the same protection!

If two doses have already been given at less than 6 months apart or if the teen is 15 years and older, the third dose will still be needed.

Addendum: 

I don't want to confuse everyone... the FDA has approved a new schedule, but the Advisory Committee on Immunization Practices (ACIP) will need to give their input before the schedule actually changes. That will be decided at their October 19-20 meeting.

One last addendum:

The ACIP approved the changes! Talk to your doctor about your child's vaccine needs. In short, the new recommendations state:
  • Kids who get the first HPV vaccine before their 15th birthday need two doses 6-12 months apart.
  • Kids who have turned 15 years old before the first dose should use the 3 dose series.
  • Kids who have gotten a 2nd dose less than 6 months after the first (regardless of age) need the 3rd dose.