Better Health: Smart Health Commentary Better Health (TM): smart health commentary

Article Comments (5)

Should You Worry About Your Baby’s Flat Head?

Figure 1

This post was contributed by guest blogger, Edward Ahn, M.D.

The head coach of a Division 1 champion women’s sports team brought her baby daughter in to me for evaluation of her flat head at the recommendation of her pediatrician.

While I was examining her baby, I started to say, “Well, I’ll tell you what she has –

She quickly interrupted, “Is it bad?”

I looked up to see fear written on this tough coach’s face. I was struck by how this benign condition can cause apprehension in so many parents.

Often, pediatric neurosurgeons like me or plastic surgeons are asked to assess babies with a flat head, also known as positional plagiocephaly. Usually, parents have developed a fair amount of anxiety, often with the underlying fear that their baby will need surgery or the brain will grow abnormally. These fears are not warranted.

Since the 1992 recommendation from the American Academy of Pediatrics to place babies on their backs to sleep in order to reduce the risk of SIDS (Sudden Infant Death Syndrome), there has been a marked rise in the number of babies with flatness on the back of the head. A number of factors may contribute to the likelihood for developing this condition: premature birth, twin birth, birth trauma with scalp swelling, and tightness of the neck muscles. Flatness most often develops on the back of the head on the side where the baby tends to rest while sleeping. In addition to the flatness, the ear and forehead on the same side are commonly advanced forward and the opposite side on the back bulges out, which increase the overall asymmetrical appearance (Figure 1). Sometimes, the flatness can be directly on the back of the head, depending on how the baby likes to sleep.

If your baby has developed a flat head, there are a few things you can do to make it better.

Take a big deep breath and relax. Plagiocephaly is a benign condition. It is very common. It is estimated that about 20% of 4 month-old babies have it. It does not require surgery. There has been no evidence that a flattened head impairs brain development or causes developmental delay.

A large study in the Netherlands showed that of all babies with plagiocephaly diagnosed and treated with repositioning, only 1 out of 4 had residual flatness at 2-3 years of age. Only a very small percentage of babies with plagiocephaly will report self-image or social issues as older children. The overwhelming majority will not even consider it an issue.

Remember that the natural tendency for the flatness is to get better. During the first year of life, a baby’s head more than doubles in size. Therefore, any flatness when the head is smaller will be less obvious when the head grows. Imagine a water balloon that is only half filled and placed on a sidewalk. The flat side may seem very prominent. Now, imagine filling the water balloon so that it doubles in size. The flat part will round out and will be much less obvious.

When detected early (4-6 months of age or before), there are simple, but effective measures you can take to treat your baby’s flat head:

1. Use “Tummy time” while awake

Since the flatness develops while babies are on their backs, you want to limit this time as much as possible. Therefore, while your baby is awake, place him so that he lies on his belly. Dr. John Graham, Director of Clinical Genetics and Dysmorphology at Cedars-Sinai Medical Center, recommends that every parent starts a routine with tummy time as early as possible. Even as soon as the baby first comes home from the hospital, while he is awake, you can place him on his belly and turn the head from side to side to keep the neck muscles loose for 4-5 minutes and work up to 10 minutes at a time. You can remember to institute tummy time by incorporating it into the diaper changing routine every day.

There is evidence that babies with limited exposure to time on their tummies have initial delays in motor development although they tend to walk by a normal age. One large study revealed that those infants who spend less time on their tummies show slower acquisition of motor milestones such as rolling, tripod sitting, crawling, and pulling to stand. Some researchers suggest that meeting motor milestones early translates into improved cognitive function later in life. See Tummy Time: Why babies need more of it than they’re getting. In other words, there is likely to be more benefit from tummy time than just the shape of the head.

2. Use Physical therapy to loosen tight neck muscles

If you recognize that your baby has a tendency to keep her head turned or cocked in one position, she likely has torticollis, or tightness of the neck muscles. In doing the neck exercises during tummy time described above, you may notice this tightness. Torticollis develops while babies are positioned in the womb and they bring it with them to the outside world. Simple exercises can loosen the neck if performed regularly. As a result, your baby will be less inclined to sleep on the flat part of her head. It’s never too early to ask your pediatrician to direct you to a local physical therapist who can perform neck loosening exercises and instruct you to do them at home. Then, continue with the exercises regularly and the flatness should improve once the torticollis has resolved.

3. Reposition during sleep

Most babies with plagiocephaly have flatness on one side more than the other. The aim in repositioning is to avoid having your baby sleep on the flat side as much as possible. Simply turn your baby so that she sleeps on the other side of her head. Physical or occupational therapists can create a foam wedge to place under your baby’s shoulder. Alternatively, you can simply use a tightly rolled-up receiving blanket under the shoulder to prop the baby up on the other side of her head. Understand that some babies resist repositioning or squirm out of it, which may limit the effectiveness of this method. Swaddling may help keep the baby in the desired position. When your baby begins to roll during sleep, repositioning becomes ineffective. However, babies who roll will only have improvement in the flatness because they no longer spend as much time lying on the flat spot.

4. Consider a helmet, but understand the pros and cons

By 6 months of age, many babies will respond well to the care I discuss above with significant improvement. However, other babies do not respond as well and the flatness remains, which can be disfiguring. Then, helmet therapy is an option. The goal of helmet therapy is to provide room for the head to grow where it is flat while restricting growth elsewhere. Helmets are worn all day (23/24 hours) for about three months depending upon the rate of response. Studies have demonstrated the effectiveness of the helmet over the more conservative treatments described above. However, understand that helmets are not for everyone. Parents need to be diligent about using the helmet as well as going to follow-up visits to adjust the helmet as the baby grows. In addition, many health insurance companies do not cover the costs of the helmet, which can be in the neighborhood of $3000, including the appointments and adjustments. You may ask your doctor to direct you to a local helmet company, where you can inquire about your particular insurance coverage.

By detecting your baby’s flat head early and following the above recommendations, you can easily make it better. Dr. Graham says, “With effective, early-onset tummy time that truly works with neck positioning and assesses for torticollis, the need for helmets to treat plagiocephaly can be prevented.” You will certainly be free of any worries about effects on your baby’s brain development or about having to visit a surgeon. Instead, you can spend more time simply enjoying your new precious gift.

***

Edward Ahn, M.D. is a pediatric neurosurgeon at the Johns Hopkins Hospital. He is the author of numerous peer-reviewed journal articles and frequent speaker on national and international platforms. Dr. Ahn has no conflicts of interest related to grants, research support, consultant or advisory boards, speaker’s bureaus or stock shareholders.


You may also like these posts

Read comments »


5 Responses to “Should You Worry About Your Baby’s Flat Head?”

  1. Debi Lennoz says:

    Does having a helmet delay any milestones , like crawling?

  2. Nello says:

    Okay…Now here’s the truth for you folks out there. My 3.5 year old daugher has a “moderate” case of positional head flatness. It’s flat on the back and flatter on one side. It did not look too bad when she was under 1 year old and the GP and online experts said not to worry about it. I wish I had ignored them. Despite using the tummy time and position changing strategies it persisted. As her head grew, rather than getting better as said above it got much much more noticeable. So if you’re worried please ignore that water balloon example above. Let’s be clear. We should have got the helmet but the doctors don’t understand it yet. You need to push the matter with them. They will catch up with reality in time. We saw a pediatric neurosurgeon and he felt it as no big deal.

    So…Our hope and prayer is that going forward from 3.5 years to when she’s older her head gets smaller and her hair growns longer. It IS true that you rarely see flat head young adults around. I do see the odd Asian with a flat head but I think that’s how God made them so it might not be the problem we’re talking about. I think girls have the advantage of longer hair. The other thing is this theme from online commentators that it’s parental vanity or something. Ignore them too. If you’re in our situation you already know that they don’t understand your problem. Their kids responded to the tummy time and change of positioning better.

    In my heart I think her hair will cover some of it and her face will become bigger and head lag behind. That happens in a few years although it’s not mentioned above. Say a prayer for all of us. It’s a parent’s job to do their best. I’d be happy to be wrong about this but it seems that the efforts to discredit the helmet sellers is unfounded. It also seems the doctors are a few years away from really understanding that some kids don’t round out at all.

    Don’t blame yourself. We followed the rules set out by the medical community to avoid SIDS. This is an unforeseen side effect of the Back To Sleep Campaign. You did nothing wrong except listen to the experts. At 3.5 yrs old no one has said anything yet but it’s noticeable. All we can do is grow her hair, forgive ourselves, and wait for things to get batter. She’s perfect in every other way :) Be strong out there. Just try to wait and ignore it.

  3. Mary says:

    My grandson is 5 months old. He has a very flat head in the back and a prominent forehead. The cranial technician advised us to have him wear a helmet. Is it too late at this stage to try “tummy time” or repositioning to change the shape of his head?

  4. Heba says:

    My 18 month son has a flat head in the back. It got better compared to when he was 6 months old but there is some. A plastic surgery needed? Will his head change since he is 18 months?

  5. Flathead says:

    “Only a very small percentage of babies with plagiocephaly will report self-image or social issues as older children. The overwhelming majority will not even consider it an issue.”

    And what about the ones of us who make up that percentage?

    My life has been severely impacted as a result of untreated plagiocephaly. I faced constant hatred and social ostracization in my community as a youth.

    Beyond that, my deformed head creates impediments to the use of safety equipment (helmets are never made to accomodate plagiocephalic heads).

Return to article »

Latest Interviews

How To Make Inpatient Medical Practice Fun Again: Try Locum Tenens Work

It s no secret that most physicians are unhappy with the way things are going in healthcare. Surveys report high levels of job dissatisfaction burn out and even suicide. In fact some believe that up to a third of the US physician work force is planning to leave the profession…

Read more »

Caring For Winter Olympians In Sochi: An Interview With Team USA’s Chief Medical Officer Dr. Gloria Beim

I am a huge fan of the winter Olympics partly because I grew up in Canada where most kids can ski and skate before they can run and partly because I used to participate in Downhill ski racing. Now that I m a rehab physician with a reconstructed knee I…

Read more »

See all interviews »

Latest Cartoon

Richmond, VA – In an effort to simplify inpatient medical billing, one area hospitalist group has determined that “altered mental status” (ICD-9 780.97) is the most efficient code for use in any patient work up.

“When you enter a hospital, you’re bound to have some kind of mental status change,” said Dr. Fishbinder, co-partner of Area Hospitalists, PLLC. “Whether it’s confusion about where your room is located in relationship to the visitor’s parking structure, frustration with being woken up every hour or two to check your vital signs, or just plain old fatigue from being sick, you are not thinking as clearly as before you were admitted. And that’s all the justification we need to order anything from drug and toxin screens, to blood cultures, brain MRIs, tagged red blood cell nuclear scans, or cardiac Holter monitoring. There really is no limit to what we can pursue with our tests.”

Common causes of mental status changes in the elderly include medicine-induced cognitive side effects, disorientation due to disruption in daily routines, age-related memory impairment, and urinary tract infections.

“The urinalysis is not a very exciting medical test,” stated Dr. Fishbinder. “It doesn’t matter that it’s cheap, fast, and most likely to provide an explanation for strange behavior in hospitalized patients. It’s really not as elegant as the testing involved in a chronic anemia or metabolic encephalopathy work up. I keep it in my back pocket in case all other tests are negative, including brain MRIs and PET scans.”

Nursing staff at Richmond Medical Hospital report that efforts to inform hospitalists about foul smelling urine have generally fallen on deaf ears. “I have tried to tell the hospitalists about cloudy or bloody urine that I see in patients who are undergoing extensive work ups for mental status changes,” reports nurse Sandy Anderson. “But they insist that ‘all urine smells bad’ and it’s really more of a red herring.”

Another nurse reports that delay in diagnosing urinary tract infections (while patients are scheduled for brain MRIs, nuclear scans, and biopsies) can lead to worsening symptoms which accelerate and expand testing. “Some of my patients are transferred to the ICU during the altered mental status work up,” states nurse Anita Misra. “The doctors seem to be very excited about the additional technology available to them in the intensive care setting. Between the central line placement, arterial blood gasses, and vast array of IV fluid and medication options, urosepsis is really an excellent entré into a whole new level of care.”

“As far as medicine-induced mental status changes are concerned,” added Dr. Fishbinder, “We’ve never seen a single case in the past 10 years. Today’s patients are incredibly resilient and can tolerate mixes of opioids, anti-depressants, anti-histamines, and benzodiazepines without any difficulty. We know this because most patients have been prescribed these cocktails and have been taking them for years.”

Patient family members have expressed gratitude for Dr. Fishbinder’s diagnostic process, and report that they are very pleased that he is doing everything in his power to “get to the bottom” of why their loved one isn’t as sharp as they used to be.

“I thought my mom was acting strange ever since she started taking stronger pain medicine for her arthritis,” says Nelly Hurtong, the daughter of one of Dr. Fishbinder’s inpatients. “But now I see that there are deeper reasons for her ‘altered mental status’ thanks to the brain MRI that showed some mild generalized atrophy.”

Hospital administrators praise Dr. Fishbinder as one of their top physicians. “He will do whatever it takes to figure out the true cause of patients’ cognitive impairments.” Says CEO, Daniel Griffiths. “And not only is that good medicine, it is great for our Press Ganey scores and our bottom line.”

As for the nursing staff, Griffiths offered a less glowing review. “It’s unfortunate that our nurses seem preoccupied with urine testing and medication reconciliation. I think it might be time for us to mandate further training to help them appreciate more of the medical nuances inherent in quality patient care.”

Dr. Fishbinder is in the process of creating a half-day seminar on ‘altered mental status in the inpatient setting,’ offering CME credits to physicians who enroll. Richmond Medical Hospital intends to sponsor Dr. Fishbinder’s course, and franchise it to other hospitals in the state, and ultimately nationally.

***

Click here for a musical take on over-testing.

See all cartoons »

Latest Book Reviews

The Spirit Of The Place: Samuel Shem’s New Book May Depress You

When I was in medical school I read Samuel Shem s House Of God as a right of passage. At the time I found it to be a cynical yet eerily accurate portrayal of the underbelly of academic medicine. I gained comfort from its gallows humor and it made me…

Read more »

Eat To Save Your Life: Another Half-True Diet Book

I am hesitant to review diet books because they are so often a tangled mess of fact and fiction. Teasing out their truth from falsehood is about as exhausting as delousing a long-haired elementary school student. However after being approached by the authors’ PR agency with the promise of a…

Read more »

Unaccountable: A Book About The Underbelly Of Hospital Care

I met Dr. Marty Makary over lunch at Founding Farmers restaurant in DC about three years ago. We had an animated conversation about hospital safety the potential contribution of checklists to reducing medical errors and his upcoming book about the need for more transparency in the healthcare system. Marty was…

Read more »

See all book reviews »