Newborns’ soft heads sometimes develop flat spots. These areas—often found in the back of the head—can be caused by several factors, including conditions known as plagiocephaly or torticollis.
Prompted by numerous reports of babies around the country succumbing to Sudden Infant Death Syndrome (SIDS) as well as a strong desire to better inform parents about the potential dangers of placing newborns on their stomachs to sleep, the American Academy of Pediatrics (AAP) published a statement in 1992 recommending that healthy infants be placed on their backs for sleep.
Two years later, the AAP launched the nationwide Back to Sleep campaign to further promote supine (back) sleep positioning for newborns. The campaign has resulted in a significant decrease of SIDS—nationwide, rates have gone down by an estimated 40 percent in the last decade—yet there has been a marked increase in the diagnosis of positional head deformities in American newborns.
“Parents and healthcare providers need to be aware that supine positioning of the infant may result in flattening of the head,” explains Robert E. Lyle, MD, associate professor, Department of Pediatrics, University of Arkansas for Medical Sciences and co-director of the Neonatal Intensive Care Unit at Arkansas Children’s Hospital. Two of the most common types of positional head deformities diagnosed in newborns are plagiocephaly and torticollis.
Plagiocephaly is a condition that causes an infant’s head to become misshapen, usually resulting with the flattening of one side of the back of the head, commonly referred to as positional plagiocephaly. (Plagiocephaly is a general term for cranial asymmetry, which basically refers to misshapen heads.) Cases of positional plagiocephaly can range drastically. Very mild cases may correct themselves with preventative measures and through repositioning exercises, while severe cases can require corrective surgery and/or the use of helmet therapy.
Congenital Muscular Torticollis
Congenital muscular torticollis, commonly known as torticollis, causes a newborn’s head and neck to tilt to one side. “An involuntary one-sided contraction of the neck muscles can occur, resulting in an abnormal positioning of the head and limitation of the neck’s range of motion,” explains Dr. Lyle, who further emphasizes that torticollis may also present itself as a result of “bleeding or scarring in the major neck muscle, but can also occur due to the persistent positioning of the head to one side—such as may occur with the supine (back) positioning of the infant at sleep time.”
Diagnosed cases of torticollis may occur in between 0.4 percent to three percent of babies, with those born prematurely more susceptible to developing this condition due to “critical illness that results in prolonged hospitalizations and the necessity for unidirectional positioning of the head, such as may occur when an infant requires a ventilator,” explains Dr. Lyle. “Special care must be directed to alternate positions of the head even while ventilated to avoid this condition.”
Diagnosis and Treatment
Both of these conditions are likely to first be diagnosed by a child’s physician, who may later refer parents to a craniofacial specialist. The specialist will then look for specific signs that may also include a long, narrow head shape; the forehead on the affected side may be slightly more noticeable than the unaffected side; and the baby may tilt his or her head to one side. These infants will undergo diagnostic testing through X-rays, computed tomography (CT) scans, and magnetic resonance imaging (MRI). These tests confirm whether or not a deformity of the head is being caused by a serious condition called craniosynostosis, which occurs through the premature closure of cranial sutures.
Both forms of positional head deformities can be avoided through a combination of specific measures. “Plagiocephaly and torticollis can be prevented through counseling and education during the early newborn period, between two to four weeks,” says Dr. Lyle. Extended time on an infant’s stomach is vital and beneficial to avoid both these conditions.
“For cases of torticollis, parents can also perform neck exercises with each diaper change. These exercises consist of a parent placing a hand on the child’s upper chest and then rotating the child’s head so that the chin touches the shoulder and is then held for approximately 10 seconds. This is then repeated on the child’s other side. This exercise, performed for three repetitions, stretches the sternocleidomastoid muscle. In addition, the child’s head can be tilted (toward both the right and the left) so that the ear touches the shoulder for a 10-second count. This exercise stretches the trapezius muscle,” says Dr. Lyle.
For those babies with a diagnosed flattening of the skull, Dr. Lyle recommends an exercise where parents should place the “rounded side of the head against the mattress, which may be helpful … parents can also change the position of the crib in the room so that the child must look away from the flattened side to see their parents or their toys.” Make these exercises a special time between you and your baby by playing soft music, and pick out toys that are stimulating to your child’s vision and other senses.
Some infants do not enjoy even brief moments spent on their tummies. Dr. Lyle advises that parents of these babies should try to ease them into the position gently. “Parents should try to alternate the position of their baby’s head each night, either right or left side, when placing them to sleep. During awake periods, the baby can be placed for appropriate tummy time as long as the parents are present observing the child throughout this time.” He also warns parents to limit the amount of time that their child spends in car seats or other infant seats that might place the baby on his or her back.
If parents and physicians notice no further improvement of the condition, or if the cases are more advanced, these babies will likely be fitted with a molding helmet or head band. Companies such as Cranial Technologies, Inc. have designed helmets specifically for children with cases of positional plagiocephaly. The DOC Band from Cranial Technologies consists of an outer plastic shell with a foam lining. The band applies pressure to capture the continuous growth of a baby’s head, holding the growth where necessary and encouraging growth in the head’s flat regions. Specific adjustments are made weekly, and the time rate of treatment depends upon both the baby’s age and severity of the deformity.
These types of skull-molding helmets can provide positive results, and according to Dr. Lyle, they can be “beneficial in situations where positioning and exercises have failed.”
Words of Advice
“Early infancy is a time of rapid growth of the brain and skull as well as a time during which the skull is malleable. Through parental due diligence and guidance by their pediatrician, many cases of positional plagiocephaly and torticollis can be prevented,” says Dr. Lyle.