Posted tagged ‘plagiocephaly’

Flat head? Helmets aren’t the answer

May 15, 2014

The Pediatric Insider

© 2014 Roy Benaroch, MD

International campaigns to reduce the incidence of Sudden Infant Death Syndrome (SIDS) have been very successful, with reductions of 50% or more in just about every country that’s pursued public education campaigns. Putting babies “back to sleep” is now ingrained in the public psyche. It’s saving lives.

But an unintended consequence has been an increase in babies with flattened heads. Doctors, who need a different word for everything, call this “plagiocephaly”, and it’s almost always caused by prolonged periods of unequal pressure on the growing cranium. If Junior sleeps on his back with his head turned to his right, the back/left of his head will always be pressed down into the bed. Over time, that side will become flatter. Over more time, if steps aren’t taken to correct this, the left ear and the left side of the forehead will shift forward. Viewed from above, the head of a baby with this kind of “positional plagiocephaly” will look like a parallelogram.

This kind of plagiocephaly—caused by pressure on the head, in the shape of a parallelogram—does not cause any developmental or brain problems. The significance is entirely cosmetic. If severe, it can be quite noticeable, but mild to moderate plagiocephaly has minimal if any cosmetic impact and no health consequences whatsoever.

Still, moderate-to-sever plagiocephaly is noticeable, and parents and pediatricians have been eager to find ways to correct it. One treatment that’s become very common is the use of a custom-made, lightweight fiberglass “helmet” that’s worn throughout the day and night. As baby’s head continues to grow, the thinking goes, it will grow into the nice round shape of the inside of the helmet. Problem solved?

But what seems to work, or what you think is likely to work, might not really work. That’s what practicing medicine is all about. We have to test our therapies and ideas, studying them objectively and impassively. We want it to work, it seems like it works, it makes sense that it does work. But does it really make any difference?

Researchers from The Netherlands just published a randomized clinical study, “Helmet therapy in infants with positional skull deformation: randomised controlled trial”. 84 infants who were already enrolled in conservative programs to address moderate-to-severe skull deformity were randomized at 5 months of age to either get fitted with a molding helmet, or to just continue monitoring alone. Helmets were worn for 23 hours a day for six months, with the helmets being re-fashioned and adjusted as the children grew.

Some red flags popped up early on. 403 infants were deemed eligible for the study, but only 21% of their parents agreed to participate—most of the parents did not want to consider joining a study where there child could be randomized to not receiving a helmet. And as the study went on, 100% of the helmet children reported what were considered significant side effects, including skin irritation, pain, decreased cuddling, and unpleasant odors from the helmets.

Still, almost all of the families assigned helmets completed the study and were compliant with therapy, and almost all of them had a full reassessment at 24 months of age to compare helmeted children with those that were just watched. What was found was stark. Use of the helmet made no difference in any measure of head shape. Unbiased observers, who didn’t know which treatment group the children were in, found that measures of head asymmetry were identical. The helmets just didn’t make any difference. Among children who wore a helmet versus those who didn’t, the same degree of improvement was seen, though complete resolution of head asymmetry was seen in only about 24% of patients in both groups. Overall, parents from both groups were equally satisfied with the improvement in their childrens’ head shape.

So what really should be done to deal with positional plagiocephaly? First, a fear of plagiocephaly should not discourage parents from setting their babies down to sleep on their backs. Safe sleeping is preventing thousands of SIDS deaths. But are ways to encourage safe sleep that won’t increase your baby’s risk of a flat head. Rotate the position of sleep, by putting Junior’s head on alternating nights and naps first at one end, then the other end of the crib. Junior will turn his head to look into the room, at the interesting parts. If his head is always on top of the bed, he’ll be looking over the same shoulder all of the time. Sometimes, place him with his head at the bottom of the crib.

Don’t use any sleep positioners—they’re not needed, and make sleep more dangerous. Don’t routinely sleep your child in a car seat, bouncy seat, or sling-shaped positioner—these can all increase the risk of plagiocephaly, and are not safe. Encourage tummy time when infants are young, and upright/sitting play when they’re a little older and ready for it.

Some children with plagiocephaly have a physical problem with the muscles in their necks, which prevents equal rotation to either side. These babies sit with their heads cocked to one side, and sometimes have a thickening you can feel in the muscle along one side of the neck. This is called “torticollis,” and can usually be treated with physical therapy.

If you’re concerned about your child’s head shape, make sure to bring it up with your doctor. Rarely, head shape problems can be a sign of a medical problem that needs to be addressed. Usually, though, a few simple steps at sleep and play times can help head shapes improve—apparently, just as much as an expensive, sweaty, unpleasant head helmet. Sometimes less is more. You don’t have to have your child helmeted for six months to get a fine looking head. Nice to know, and one less thing to worry about!

Is Tummy Time really essential?

March 17, 2014

The Pediatric Insider

© 2014 Roy Benaroch, MD

Fiona has had it with “Tummy Time”! She wrote: “Doctors, prenatal classes, books, other Mums all stress that it’s vital for preventing a flat head and strengthening muscles.  But my little monkey screams blue murder the second I put her on her tummy.  What’s the evidence behind this (fairly recent?) exhortation to put babies on their tummies for a few minutes every day? Have people always done it, and if not, were kids in times gone by somehow delayed in their motor development? My instinct says no, but the call for tummy time seems to be so ubiquitous. And if it’s so important, how do we convince the babies who resist? Mine spends much of her awake hours sitting upright in a sling so I guess she gets a neck workout that way and isn’t lying on her back all the time risking flat-headedness, but it’d be nice to be reassured!”

Tummy time isn’t supposed to be “torture time.” If your baby absolutely hates it, pick her up. There’s no great evidence that it’s necessary at all.

The growing enthusiasm for tummy time began with recommendations in the 1990s that babies be put down to sleep on their backs, rather than their tummies. This led to a dramatic drop in deaths from SIDS, but an increase in what’s formally known as “positional plagiocephaly”, or flat little heads. It turns out that when Junior sleeps on her back, especially with her head turned to the same side all the time, that side gets kind of flatter. There’s no significant medical issue here—heads flattened in this manner don’t cause brain damage or developmental problems—but in severe cases it can be noticeable.

There are good ways to prevent flat heads. The AAP recommends alternating head positions from night to night, and periodically changing around the positioning of the crib so interesting things aren’t always in the same position (you can accomplish the same things by alternating which end of the crib is “up”, or which end the head and feet point to.) And, yes, as part of the anti-flat-head routine, the AAP recommends “a certain amount” of supervised “tummy time” when Junior is awake. They acknowledge that there’s no evidence that this helps, and no studies have shown how much tummy time is ideal, or at what ages it’s needed. It’s more of a common-sense thing. More time on tummy means less time on back, which should not only prevent flat heads but also facilitate motor development by giving Junior a chance to work on her push-ups. So for the many babies who don’t mind some tummy time, I think it’s probably a good idea.

If you’ve got a baby who’s starting to look a little flat in the head department, talk with your pediatrician. Re-orient the crib to encourage Junior to look the other way, and try to alternate head positions and increase tummy time. Your pediatrician should also check for torticollis, a muscular condition that makes in difficult for babies to turn their heads in both directions. Rarely, a molding helmet can be used to help heads grow more round in shape, but beware that companies are marketing these directly to parents, and many babies with mild asymmetry really don’t need anything special, just some repositioning and time to grow and develop.

But for babies like Fiona’s, who absolutely hate tummy time, there’s no reason to think it’s critical. I’d try to make tummy time more fun, if possible, by lying down with the baby so she could see me. But bottom line: if she’s hysterical, pick her up. This issue is not worth any misery.