Wednesday, November 15, 2006

Plagiocephaly

Dear Lisa,

I went to the Pediatrician’s office for a four month old visit for my son and the doctor told me that my son has Plagiocephaly. I noticed that his head was flat in the back, but I didn’t think that it was a big deal. I don’t understand why he got this and my two other children didn’t. I handled all of them the same way. Why did this happen to him and not my other two?

“Son has a Flat Head ”

Dear “Son has a Flat Head”,

Plagiocephaly is a distortion of the shape of an infant’s malleable skull due to external molding. Positional Plagiocephaly develops when pressure or forces cause an infant’s soft skull to become misshapen, asymmetrical and flat in certain areas. Positional Plagiocephaly is a very common condition found in nearly 10% of all children.(1)

There are many factors that contribute to the development of Positional Plagiocephaly. A restrictive uterine environment is considered one of the leading risk factors.(1) Other risk factors include; prematurity, low birth rate, a baby with a large head, multiple births, breech presentation, increased uterine or abdominal muscle tone, small maternal pelvis, medical conditions that predispose infants to maintain their head in a consistent position and “back to sleep positioning”. (1)

In particular there has been an increased incidence of Positional Plagiocephaly in recent years. This finding is attributed to the practice of putting babies “Back to Sleep”. This increase in the incidence of Positional Plagiocephaly coincides with the introduction of the American Academy of Pediatrics “Back to Sleep” positioning recommendation instituted in the early 1990’s. (2,3) This recommendation was made with the goal of decreasing the risk of Sudden Infant Death Syndrome. The campaign was a success because there has been a decrease in the incidence of Sudden Infant Death since the recommendation was made.

This change in sleep position resulted in babies spending much more time on their backs. Spending a significant amount of time on the back contributes to the formation of a flat occiput and positional molding leading to Positional Plagiocephaly. The good thing about Positional Plagiocephaly is that it is not a life threatening disorder and if treated early, it can be corrected.

The reason why one sibling develops Positional Plagiocephaly and another doesn’t can be due to a multitude of factors. First of all, boys are more commonly affected then girls. Secondly, your son’s intra-uterine environment could have contributed to his condition. Perhaps his position in utero lent it self to pressure on certain spots of his skull. Secondly, his head size may be different from your other two children. Or perhaps, after delivery your son spent more time flat on his back as compared to your other two children. The important thing is that the problem was identified early so that measures can be taken to improve his Positional Plagiocephaly.

You can ask your Pediatrician about measures that you can take in order to correct your son’s misshapen head. The key to successful management of infants with Deformational Plagiocephaly is early diagnosis and treatment. (4) Since 80 % of skull growth takes place before 12 months there is a small window of opportunity available to provide treatment. Typically, the earlier the deformity is identified and treated, the greater chance of correcting the problem completely. (5)

Most interventions rely on redirecting symmetrical growth of the skull. (4) The measures that can be taken to accomplish this include repositioning the head off of the flat spot, position changes, environmental changes and supervised “tummy time”. A parent can reposition the infant’s head by turning the head to the side, off of the flat spot. This is quite difficult when a child is awake because they tend to maintain a position of comfort and resist re-positioning. (4) A good time to re-position the head is 30 minutes after a child falls asleep. At this time there is less resistance to change in position and the greater chance that the head will remain the way it is re-positioned.

The parents should alternate arms when holding and feeding the infant. This will prevent the child’s head from remaining in the same constant position at all times. (4) The infant’s environment should also be changed frequently. Parents should rotate the position of the toys in the room and the placement of the infant seat. (4) If an infant is put in the infant seat in the same spot of the room each day, he will learn to tilt or turn his head in the same direction in order to see the main activity in the room. By frequently changing the placement of an infant in the room, it forces him to tilt his head and stretch his neck in different directions in order to see the activity.

Putting the baby down to sleep on alternating sides of the crib each night also encourages symmetric growth of the skull. This way, each morning the infant will need to look in a different direction to see mom and dad come into the room. The frequent change in head position encourages range of motion of the neck and rotates the pressure sites on the skull which promotes a more symmetric shape.

Supervised “tummy time” during the day is also recommended. Spending time on the belly helps the baby develop muscles in the abdomen, upper chest, neck and arms. Tummy time takes the pressure off of the back of the head and encourages symmetrical growth of the skull. Many parents report that their baby cries when they put their baby on the belly and because of this immediately put the baby on the back again. (4) Parents who encounter this problem can try positioning toys or a child-proof toy mirrors in front of the child during “tummy time” to help keep the baby in the position for a longer time.

I found in my practice that babies who engaged in “belly time” since birth seemed to be used to the position and tended to have less crying. This is one of the reasons why it is important for all babies to have supervised “tummy time” starting early in infancy.

Physical therapy and neck stretching exercises play an important part in treating Positional Plagiocephaly. Most children with Positional Plagiocephaly also have some form of neck dysfunction. (4) Neck stretching exercises can alleviate the restriction in movement and allow the infant to alter its head position more freely.

Children with severe deformities that do not improve with more conservative measures can benefit from Orthotic management with the use of a helmet or band. (6) The helmet works by applying a mild constant pressure on the most anterior and posterior prominences where growth is undesirable. At the same time room is left in the flattened regions in order to encourage the cranium to grow. The helmet is adjusted frequently to monitor improvement and ensure proper growth of the head. Numerous clinical studies have demonstrated the success of this technique.(5,7)

I have had plenty of parents who were concerned that the helmet would hurt the infant or interfere with the child’s movement. From my experience, infants tolerated the helmet very well and moved as if there was nothing on their head at all. I also found that the parents were very pleased with the final results.

For more information about Positional Plagiocephaly read the following Pediatric Advice Story:

Infant with Neck Hung to the Side

References:
(1)Carson, B., Munoz, D., Gross, G. An assistive device for the treatment of positional plagiocephaly. J Craniofacial Surgery. 2000;11(2): 77-183.
(2)Komotar, R., Zacharia, B., Ellis, J., Feldstein, N., Anderson, R. Pitfalls for the Pediatrician: Positional Molding or Craniosynostosis? Pediatric Annals: 2006;35(5):365-375.
(3)Peitsch, W., Keefer, C., LaBrie, R., Mulliken, J. Incidence of cranial asymmetry in healthy newborns. Pediatrics. 2002;110(6):e72.
(4)Littlefield T, Reiff J, Rekate H. Diagnosis and Management of Deformational Plagiocephaly. BNI Quarterly. 2001. 17(4):1-8.
(5)Kelly KM, Littlefield TR, Pomatto TK. Importance of early recognition and treatment of deformational plagiocephaly with Orthotic Cranioplasty. Cleft Palate Craniofac J. 1999. 36:127-130.
(6) Komotar R, Zacharia B, Ellis j, Feldstein N, Anderson R. Pitfalls for the Pediatrician: Positional Molding or Craniosynostosis? Pediatric Annals. 2006. May:365-374.
(7)Littlefield TR, Beals SP, Manwaring KH. Treatment of Craniofacial asymmetry with dynamic Orthotic Cranioplasty. J Craniofac Surg. 1998.9:11-13.

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

Pediatric Advice For Parents

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