Flat heads in babies

We have significantly decreased the risk of SIDS by placing babies on their backs to sleep, but have seen a rise in flat heads due to their positioning. Prevention of the flatness involves several positioning strategies.

Supervise tummy time when Baby's awake!

It's important for babies to sleep on their back, but they tend to have their head facing one direction or another. They should alternate which side they face, but many babies have a stiff neck and favor looking to one side. Think of when you wake with a stiff neck - probably from positioning overnight. Many babies are in the same position for quite awhile at the end of pregnancy - of course they're stiff!

If Baby's neck is stiff, you can massage his or her neck and shoulder muscles gently and then slowly move the head right and left (chin to each shoulder) and side to side (ear to shoulder). Don't quickly force the head movement, but think of what you do if you have a stiff and sore neck. The more frequently you stretch it out, the better it feels, right? I recommend stretching Baby's neck with each diaper change (before the change or after you wash your hands!) until it isn't stiff for several days and Baby moves his or her head easily without your help.

Start supervised tummy time early on - the longer you wait to start, the more Baby might resist it. I see so many parents who are hesitant to put Baby on his or her stomach. Concerns range from the umbilical cord stump still being on and bothering the baby (it won't) to spitting up will worsen (test it out, for many babies it's actually better) to "I thought babies should never be on their stomachs" (only when sleeping or not supervised).

Tummy time is an important time for baby to develop muscle strength. It needs to be supervised, but it can be a fun time to interact with Baby. Lay face to face and talk to Baby, encouraging him or her to look up. Grab a brightly colored object and move it around for Baby to watch. Enjoy your play time.


For more information on issues related to stiff necks in babies and how to treat the stiffness, see this Torticollis information.

AAP article on how to prevent flat heads in babies.

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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.

Bumps, ridges, and soft spots on baby's head

Parents often worry about lumps and bumps on a baby's head unnecessarily. Babies normally have ridges and soft spots on their head for a while after birth. Many have a type of swollen gland that parents can feel when rubbing the head.

All of this is normal.

Let's begin with a brief overview of a baby's head. We are born with many bones in our skull. This allows the head to be squeezed out of the birth canal as the boney plates move together or even overlap one another.

photo source: Shutterstock

Sometimes you don't really notice much with these bones, but other times they still overlap one another noticeably after birth. A baby might have a cone shaped head after birth, but this usually quickly reshapes into a round head over a couple days.

There are 1-2 "soft spots" at birth. Usually the one on top to the head (the anterior fontanelle) remains open enough to feel for the first 18-24 months of life. The one towards the back of the head (the posterior fontanelle) is unable to be felt by about 2 months of age. Many parents fear that touching the soft spot will somehow damage the baby's brain. Normal touching won't hurt, even from a 2 year old sibling. There are several layers of skin and other tissues protecting the brain. Doctors will feel the soft spots during routine check ups to be sure they are the right size for the growth of the baby's head. (There's a lot of variation here, so if you question the size of your baby's soft spot, discuss it at a visit with the doctor. He or she will need to not only feel the soft spot, but also will look at overall head growth, baby's development, and the shape of the head.)

Coming out of the birth canal can be traumatic for both mother and baby (and often for fathers too). Sometimes babies have a big soft or squishy bump on one side of the head, which usually is essentially a large bruise. The two most common causes for this are cephalohematoma and caput saccedaneum. A cephalohematoma develops when there is bleeding between the skull and the bone lining called periosteum. Since it is outside the skull, it doesn't affect the baby's brain. It covers only one of the bones, and never crosses one of the suture lines. A caput is from bleeding one layer above the periosteum in the skin. It can cross the bone areas since it's not limited by the lining of the bone (periosteum).  Both of these conditions can lead to increased risk of yellow jaundice due to breakdown of the blood collections, but usually self resolve without complications. If baby seems uncomfortable due to this area, discuss with your hospital nurse or doctor.

This picture attempts to show the layers of bleeding described here and includes more uncommon (and more concerning) types of bleeding.

photo source: http://en.wikipedia.org/wiki/File:Scalp_hematomas.jpg

Flat spots are common, especially if babies prefer to always look to one side. This can cause the forehead to seem to bulge on one side or an ear to appear closer to the face than the other ear. This is usually due to baby laying one direction most of the time, allowing the brain to grow all directions but spot baby is laying on. It is important to get baby to lay looking right sometimes, left other times. Supervised tummy time is helpful too. (I recommend starting tummy time day one. The earlier you start tummy time the less they seem to hate it!) When you hold and feed baby, alternate arms because they will look toward you and by simply holding in the right arm sometimes, left arm other times, they will turn their head. If your baby resists turning his head, check out this Torticollis information.

One of the most common head worries that brings parents to the office is a pea-sized (or bigger) movable bump on the back of baby's (or even an older child's) head. This is usually an occipital lymph node. When I say it's just a lymph node, some parents automatically worry about lymphoma. Don't go there. Most of us remember having a swollen lymph node (AKA swollen gland) under our jaw or in our neck when we are sick. When they develop on the back of the head, it is usually from something irritating the scalp, like a scalp probe during labor, cradle cap, or bug bites in older kids. They can remain large for quite a while (often seeming to come and go when kids have scalp irritations), but unless they hurt to touch, enlarge rapidly, are red and hot, or a child looks sick otherwise, I don't worry about them.

photo source: Shutterstock

In short, most lumps and bumps on your baby's head are normal. If you're worried, bring your baby in to have your pediatrician look and feel.

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