Infant with Neck Hung to the Side

Dear Lisa,

We recently had a new baby that was delivered with forceps. She is now nearly 4 months old. Her left eye has always appeared smaller that the right one, and she "hung" her neck to the right for quite sometime, almost as if there was some sort of nerve or muscle damage, now we have noticed that her pupil in her right eye does not dilate the same as the left eye. So far the doctors have not been concerned about any of this but I have two other children and have never experienced this before. Sometimes we are not even sure that she is hearing properly, she doesn't seem to really respond to noise as you would expect. What should we be concerned about if anything, and what type of doctor should we have her see?

"Four month old with Neck Hung to the Side",

Dear "Four month old with Neck Hung to the Side",

Many times infants develop a cluster of symptoms that are considered variations of normal. Other symptoms may represent minor alterations that typically resolve on their own or with minimal intervention. Sometimes these symptoms may be related to each other and in others, they may represent individual findings. It is normal for parents to become concerned, especially if these variations differ from the appearance and behavior of a child’s siblings. Open communication with your child’s doctor can help clarify which symptoms are normal and which need further evaluation. Sometimes the time constraints in the doctor’s office limit the amount of time for explanations. I will go over each symptom step by step so that you can direct your discussion and ask pertinent questions at your next doctor’s visit or with a specialist if necessary.

Some of the symptoms that your are describing may be consistent with Plagiocephaly and Torticollis. One of the most common reasons for an infant to prefer one side, have their head “hang” to one side or tilt her head is Torticollis. Torticollis occurs when there is a unilateral (one sided) shortening or contracture of the sternocleidomastoid muscle which results in a restriction of the movement of the neck. (1) This positioning of the neck is usually due to a shortening of the muscle that rotates the head to the opposite side and tilts it towards the involved side. Torticollis may also occur when there is a weakness of the muscles on the opposite side of the neck. (2, 3) In most cases Torticollis is caused by the positioning of the baby in utero before it is delivered or due to positioning of the baby after birth. In rarer cases Torticollis may be due to an injury to the muscle or a mass in the neck. (1)

Ever since 1992, when The American Academy of Pediatrics recommended the ”Back to sleep” positioning for infants there has been an increase in the amount of children with positional molding (misshapen and flat heads) and Torticollis (crooked necks). (2,4) Because babies spend so much time on their backs the bones in the skull develop a flat shape which lends itself to a position of comfort with the neck turned or twisted to one side. (4) Signs of Torticollis may include asymmetric face(one side looks bigger than the other), asymmetry of the skull(the shape of the skull is not even), downward placement of the orbit (bones around the eye), Plagiocephaly, head tilt to one side, decreased range of motion of the neck and resistance to movement of the neck. (1, 2) Infants with Torticollis commonly experience positional molding or Plagiocephaly at the same time. (3) Infants with Plagiocephaly present with a misshapen head, asymmetric placement of the ears, bulging of the forehead and asymmetric appearance of the eyes. (5)

The majority of infants with positional molding and Torticollis improve between 3 to 6 months old, when they begin to sit up more and spend less time lying on their back. (4) In most cases the symptoms can be alleviated and the condition resolved with stretching exercises and repositioning. (1,2) I have found that many babies require interventions including home exercises, frequent position changes, supervised belly time and physical therapy in order treat Torticollis and positional molding. A better outcome is achieved if these treatments are initiated early. (1,2)

In some cases a child with positional molding or Plagiocephaly is referred to a Pediatric Neurosurgeon or a Craniofacial Surgeon for an evaluation. Diagnostic testing may be performed in order to determine the cause of the Plagiocephaly. (2) For resistant or severe cases a helmet or DOC band may be recommended. If a child has severe enough Plagiocephaly that warrants treatment with a helmet, the intervention should be started between 4 and 12 months when the skull is developing. The best results are found when helmet therapy is started early, preferably around 4 months of age. (4)

You should ask your daughter’s Doctor the cause of her symptoms, if they are considered normal variations, the progress of her neck condition and if there are any interventions that can be performed to assist in her development. It would be important to find out if there are any measures you can take at home to monitor her progress or treat her condition.

Although a child with positional molding and Torticollis may present with asymmetry of the eyes, this asymmetry is due to the formation of the bone structure and has nothing to do with the dilation of the eyes. Both eyes should dilate and constrict equally. Anisocoria is the term used to describe the condition of unequal pupil size. This condition many times is present in an infant since birth and may be considered normal. (6) It is not uncommon for a child to have Anisocoria since birth and not be discovered until a later date. Many times the differentiation between the pupil and the iris is very difficult to determine early in infancy, especially if the infant has dark colored eyes. In some cases Anisocoria may be related to central nervous system disease. (6) In order to determine if your daughter has Anisocoria or a problem with her vision you can have her evaluated by a Pediatric Ophthalmologist.

Occasionally pediatric ophthalmologic disorders may present as a head tilt to one side. A child tends to tilt their head in order to see something because they can’t visualize it clearly with the other eye. An infant with a persistent head tilt, despite the institution of stretching exercises, positioning and physical therapy should see a Pediatric Ophthalmologist for an evaluation. A Pediatric Ophthalmologist specializes in pediatric eye conditions and can determine if your child’s symptoms are due to a problem with her eyes. In order to determine if any eye condition is present since birth or if it is a new development, many Pediatric Ophthalmologists request that parents collect serial baby photographs and bring them to the visit.

Typically a newborn’s hearing is evaluated at birth in the hospital before discharge. You can ask your baby’s doctor for the results of your daughter’s hearing test or request records from the hospital where she was born. In general a parent can determine if their infant is hearing at home by watching for a response to noise. An infant should turn its head to the source of a sound. If an infant doesn’t turn her head to the source of a sound this could be because there is a problem with the movement of her neck or because she has a problem hearing.

If at any point during infancy a parent notices that their child is not hearing or responding to noise, a hearing test can be performed in order to rule out a hearing deficit. Hearing tests can be performed in The Speech and Hearing Department of a Children’s Hospital. If you feel that your daughter is not responding to a source of sound you should discuss this with her Doctor who can request a hearing test in order to alleviate your concerns.

It is quite normal for parents to be interested in getting a second opinion regarding their child’s condition by seeing specialist. Many times seeing a specialist helps alleviate a parent’s concerns and gives the situation a new perspective. In order to address all of your concerns, a different specialist for each condition would need to be consulted. A Pediatric Ophthalmologist addresses a child’s vision and rules out eye disorders. A Pediatric Neurosurgeon or Craniofacial Surgeon addresses symptoms consistent with Plagiocephaly and Torticollis. A Physical Therapist addresses and treats a child’s Torticollis. An Audiologist performs hearing tests and evaluates a child’s hearing. Your daughter’s doctor can guide you to the proper specialists in your area.

References:
(1)Behrman R, Kliegman R. Nelson Essentials of Pediatrics. Philadelphia ,PA: W.B.Saunders Company. 1990:691.
(2)Littlefield T, Reiff J, Rikate H. Diagnosis and Management of Deformational Plagiocephaly. BNI Quarterly. 2001;17(4):1-8.
(3)Kerry G, Beals S, Littlefield T, Pomatto J. Sternocleidomastoid Imbalance Versus Congenital Muscular Torticollis: Their Relationship to Positional Plagiocephaly. The Cleft Palate-Craniofacial Journal. 1999;36(3):256-261.
(4)Komotar R, Zacharia B, Ellis J, Feldstein N. Anderson R. Pitfalls for the Pediatrician: Positional Molding or Craniosynostosis? Pediatric Annals. 2006;35(5):365-374.
(5)Kelly K, Littlefield T, Pomatto J, Ripley C, Beals S, Joganic E. Importance of Early Recognition and Treatment of Deformational Plagiocepahly with Orthotic Cranioplasty. The Cleft Palate-Craniofacial Journal. 1999;36(2):127-130.
(6)Chow M, Durand B, Feldman M, Mills M. Handbook of Pediatric Primary Care. Albany, New York:Delmar Publishers Inc. 1984: 639.


Lisa-ann Kelly R.N., P.N.P.,C.
Certified Pediatric Nurse Practitioner

Pediatric Advice About Infant Development