Mothers know best.
Not long after opening this web site, a good friend emailed me to say that she thought the content of the information in some areas was a bit too technical for many readers. I have always considered myself a regular guy and I pride myself on my ability to explain medical issues to my patient’s in non-medial parlance and using simple examples and analogies. Nevertheless, I gave strong consideration to her comments and she is very articulate and a bit of a plagiocephaly expert in her own right. Lisa is the mother of 6 boys, all of whom had clear evidence of torticollis at birth (strong head rotation preference) and, consequently, had a high proclivity for developing head flattening. Her two older boys were small children when we met her family in the Boston suburb of Norwood many years ago, and they both had significant and quite visible cranial flattening. Both had been managed with repositioning, and one had treatment with a molding helmet. The orthotic did not fully correct the head shape nor the facial asymmetry that exists with most moderate to severe cases of plagiocephaly. By the time her third boy was an infant, we had just developed the PerfectNoggin mattress (at that time called the PlagioCradle) and he became one of the first patients to use the new layered design. He was already a few months old and had established flattening when he started using the device, but it did help his head shape significantly. She kept the mattress and for the subsequent three boys, including her newest addition (all of whom had a strong head rotation preference at birth), and all were placed on the mattress during sleep almost immediately after being brought home from the newborn nursery. Their head shapes are very symmetrical. She is a strong advocate of early sleep surface modification and is a bit of an expert in this area.
After years of clinical practice in pediatric plastic surgery, I have learned many things but perhaps none more important than this- listen to mothers. They have an insight into and intuition about their kids that usually transcends what any clinician can derive from a 15 minute office visit. It is a critical mistake to summarily dismiss the concerns of any mother about her child, regardless of how much one thinks he or she knows about the condition. All this to say that I must concede to an experienced mother- my simple explanations may, in fact, not be so simple! I have asked her to write a version of the text that is more user-friendly, and she will also be an occasional guest on the blog. While she is editing, I offer a summary of the top 10 things parents should know about plagiocephaly.
It only affects between 15-20% of all infants, so back sleeping is not the primary risk factor. Back sleeping merely accelerates the rate of deformation in at-risk infants.
At risk infants share a common element- limited head mobility in the first several month of life.
All described risk factors fall into four major categories- torticollis, prematurity, developmental delay, and iatrogenic causes (e.g., intubation, swaddling)
Torticollis is the largest risk factor by far and is grossly under-recognized even my clinicians; the earliest marker is a consistent head rotation preference (favorite side) early in life.
Torticollis is self-resolving in almost all instances and does not require aggressive management; Botox and surgery for torticollis should only be considered in a child older than one year of age who still has a persistent head rotation discrepancy (NOT intermittent head tilt)
Repositioning is impractical and ineffective for at-risk infants (especially torticollis). It works great for the 80% of infants who were never going to develop flattening!
The most efficient management of an at-risk infant is sleep surface alteration to replace the flat mattress surface with a concave surface.
Helmet therapy is very effective if done properly (see below)- studies to the contrary use oblique cranial ratios which artificially dilute asymmetry as the head grows.
Helmets work better if done at a younger age (but work as long as there is growth remaining), if they are made well (see helmet blog), and are worn consistently (>20 hours/day).
There is no credible evidence that plagiocephaly CAUSES developmental delay, dental issues, TMJ dysfunction, visual loss, spinal deformity, or any other medical issue.
