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.