Kids learn a lot in the first months and years of life — and research shows the brain continues to develop into the mid-20s. So the skull has to make room for all that growth. Not to mention a baby’s relatively large head must be able to fit through the birth canal. Fortunately, the skull is designed to meet those unique demands.
“The skull of a child is not made up of one single bone but rather several bones that are separated by what we call sutures — and sutures are sort of spaces between the bone,” says Dr. Peter Taub, a professor of surgery, pediatrics, dentistry and neurosurgery at the Icahn School of Medicine at Mount Sinai in New York City and director of the Mount Sinai Cleft and Craniofacial Surgery Center. That allows the bones to overlap, so that a baby’s head can fit through the birth canal during childbirth. Then the skull rebounds to a normal position, Taub explains.
As a result, it’s not abnormal for a baby’s head to have a bit of a cone shape or otherwise initially be noticeably asymmetrical after the child is born. And — as new parents are repeatedly reminded — babies’ heads are soft, and somewhat malleable to accommodate significant future brain growth.
However, in the early months of a child’s life, some parents and pediatricians may notice that one side of the head becomes flattened and — though no one’s skull is perfectly symmetrical — that this noticeable asymmetry persists. In such cases, clinicians say the problem could be what’s called flat head syndrome, or positional plagiocephaly. “Flat head syndrome is pretty much what it says: In infants, a part of their head can become flat,” says Dr. Kate Cronan, a pediatrician at Nemours/Alfred I. duPont Hospital for Children in Wilmington, Delaware, and medical editor for KidsHealth.org, part of Nemours Children’s Health System, which covers pediatric health topics including flat head syndrome, or positional plagiocephaly. “Most often it’s the back of the head.”
[See: 10 Things No One Tells You About Breast-feeding.]
Positional plagiocephaly tends to occur in the first months of life, before a baby is physically able to change positions — like not being able to move off their back — on their own. Experts point out that cases of flat head syndrome have increased with the advent of the “Back to Sleep” Campaign, which was initiated in 1994 (it’s since morphed into the “Safe to Sleep” campaign). The initiative was a collaboration between the National Institute of Child Health and Development, the American Academy of Pediatrics, the Maternal and Child Health Bureau of the Health Resources and Services Administration and sudden infant death syndrome groups aimed at reducing the risk of SIDS. While it’s been successful in combating SIDS and experts certainly aren’t going back on that safety advice to have children sleep on their backs to reduce the risk of suffocation and SIDS, clinicians say that change has led to a rise in the incidence of flat head syndrome. “Since the 90s, we’ve seen a lot of kids with flat backs of their heads,” Taub points out.
The concern is a cosmetic or aesthetic one; doctors point out it doesn’t inhibit brain development or affect a child’s cognitive function. And clinicians say the prognosis is generally good — particularly if caught early.
But first experts say it’s important to rule out other, more serious skull deformities. One particular issue doctors keep an eye out for involves the premature fusion of bones in the skull before a baby’s brain is fully formed, which can cause the head to have a misshapen appearance. So while it’s normal during the birthing process for bones in the skull to overlap then rebound to their normal position thereafter, “what we worry about is if any of those spaces, or sutures, closes prematurely — and that’s called craniosynostosis,” Taub says. This is typically treated with surgery to open the fused sutures and ensure the brain has room to grow.
“Early identification of any asymmetry of the head is usually performed by the pediatrician,” says Dr. Amanda Gosman, division chief and director of craniofacial surgery at Rady Children’s Hospital-San Diego and chief of plastic surgery at the University of California, San Diego. A craniofacial surgeon may also evaluate a child to determine what’s causing the asymmetry and if it’s something more serious like craniosynostosis.
In addition to checking to see if sutures have fused, doctors evaluate the mobility of the baby’s neck. “Because the neck can frequently contribute to some of these problems if there is a diagnosis of torticollis, which can be kind of a twisting or shortening of the neck muscles,” Gosman explains. Torticollis predisposes kids to having some asymmetry in their head shape, limiting their ability to turn their head, so that they’re more inclined to lay with one side of their head consistently in contact with a sleeping surface, for example; and in some cases a child can develop not only torticollis but flat head syndrome as well before birth, depending on how the child was positioned in utero.
Fortunately, addressing flat head syndrome doesn’t require surgery and most commonly deformities are mild and tend to improve with relatively limited intervention.
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Parents are advised, for example, to routinely reposition their baby’s head, like when putting a child down to sleep or going in to check on the child, so that the flat spot isn’t always in contact with the crib mattress or another flat surface. “Because the skull shape is very much influenced by the growth of the brain, as long as there’s some kind of off-loading and changing in position, a lot of the mild deformities that we see immediately after birth will actually correct with repositioning,” Gosman says. A pediatrician or physical therapist can provide more detailed instruction for parents on how to do this. A physical therapist can also address torticollis. “If there is torticollis, they would be working on that, too — like gentle movement of the neck; and that does take training to do that,”Cronan says. “You wouldn’t want to move a stiff neck by yourself. So if that baby has both the flat head and the neck issues, they could help with both.”
Along with regularly changing a baby’s position, which can help to prevent flat head syndrome as well, experts also reinforce a concept that’s routinely promoted for growing babies: tummy time. While it’s strongly recommended that parents place babies on their backs to go to sleep, allowing for plenty of supervised time on their stomachs is also advised. This helps babies, particularly as they’re starting to gain head control, to build neck muscles and provides an opportunity, as they’re able, to push up with their arms. In the context of flat head syndrome, it’s more time they’re not lying on the flat spot.
Another strategy — and no judgment intended — is to “hold your baby more,” Cronan says. “I know parents know to hold their babies,” but she points out that this is a great way to change your baby’s position, and so its head isn’t lying flat in the same way it would be in a crib or bassinet or on another surface.
For more severe cases of flat head syndrome, a doctor may recommend the baby wear a custom-molded helmet. The helmet has foam on the inside, it’s rigid on the outside and “it leaves space where the skull should be out further, and puts gentle pressure on the area of the skull where it’s just out a little bit too far,” Taub explains. “So it really is influencing which way the brain pushes out on the skull — because the brain’s going to want to push circumferentially, but it will be nudged to the area of least resistance.”
As with other approaches to address positional plagiocephaly, early intervention is key when using a helmet to address a child’s skull deformities. Taub says he usually doesn’t start to use a helmet until a baby has some head control — so the child can at least keep his or her head up. “So that’s usually about four to five months … up until about a year. Past a year, the bone’s pretty stiff, and you’re not going to get much change with a helmet. But early on they can be successful,” Taub says. “Kids in our program usually wear them for about four to six months.” During that period, they have them on about 23 hours a day, with a break to take a bath, snap a picture or just to get the head and scalp some air — whatever parents want to do, he says.
There are also so-called positional pillows marketed to help with flat head syndrome, to move a child off the flat spot. “We use pillows all the time for plagiocephaly in the NICU where the infant can be observed,” Taub says, adding that positional pillows are OK just so long as a parent is watching the child. The AAP advises against putting babies to sleep on or near any pillows or other positioners like wedges to reduce the risk of suffocation and SIDS; the Food and Drug Administration similarly advises children should be placed on their back to sleep on a firm, empty surface and not on a sleep positioner, like a pillow.
[See: How to Promote Safe Sleep for Your Infant.]
Usually, for kids with flat head syndrome, it tends to improve — at least to some degree — even without intervention. But experts say that, especially where it’s more noticeable, it’s important to take action early. “Generally if you didn’t have a helmet, the kids would improve somewhat,” Taub says. “But you gotta be aggressive about keeping them off that flat spot.”
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What to Do About Flat Head Syndrome in Babies originally appeared on usnews.com
