Trisha Williams (Host 1): Hi, guys. Welcome to the Advanced Practice Perspectives Podcast. I'm Trisha Williams.

Tobie O’Brien (Host 2): And I'm Tobie O'Brien. This is a podcast created by Advanced Practice Providers for Advanced Practice Providers. Our goal is to provide you with education and inspiration. We will be chatting with pediatric experts on timely key topics and giving you an inside look at the various advanced practice roles at Children's Mercy.

Host 1: Today, we are pleased to have Kelly Patterson with us. Kelly is a pediatric nurse practitioner in our Plastic Surgery Department. Welcome to the podcast, Kelly.

Kelly Patterson: Thanks for having me.

Host 2: Absolutely. Kelly, we're so glad that you could join us. Why don't you tell our listeners a little bit more about yourself?

Kelly Patterson: Well, I am a native Kansas Citian, born and raised here. I've spent equal times on both sides of the state line. I've been a nurse since 1994, and I was a late bloomer as far as going to graduate school, and I went back when I was 40. So, this is kind of almost a second career, but a continuation of a career for me. And I'm a long lifer at Children's Mercy in Kansas City. This is my third tour of duty there. I love working there, and I love the people. And I have a wonderful supportive boyfriend and two kids that are at the University of Missouri and two bonus kids, one's at KU and one's at a local community college here in Kansas City area.

Host 1: Raising those young adults is difficult.

Kelly Patterson: And expensive.

Host 1: And expensive. I hear you. Kelly, we are so excited to have you on today and have you share some of your expertise. Would you mind kind of giving us a general overview of the types of diagnoses that you see in Plastic Surgery Clinic?

Kelly Patterson: Yeah, absolutely. I want to first start off by kind of saying the difference between the words plastic surgery in an adult population versus the use in Pediatrics. When you think of plastic surgery, of course, people think of breast enhancements and fillers and all sorts of surgeries. And yes, that is part of what the training goes into. But in pediatrics, we focus on restoring children to their state of normalcy. So, when a lot of parents ask us, "Is this cosmetic?" We kind of shy away from that word. Our favorite word to use is restorative.

So with that kind of in mind, the overview of things that we see sort of fall into several different categories. One of the broadest ones is craniofacial conditions, which we're going to get into a little bit later. And under that umbrella falls things like cleft lip and palate, which I know a lot of people have worked with kids with these diagnoses. And then, the other big one in that area is craniosynostosis. And then, we also see kids with other types of craniofacial conditions. So, we see kids with macrostomia, hemifacial hypertrophy, all different things under that category.

Another big one is skin lesions. So, we do have a lot of referrals and things with skin, including dermoid cysts, which are pretty common; other kinds of cysts, as well as different nevi, so congenital melanocytic nevi, or just your garden variety moles and lumps and bumps. And we do kind of play in the same sandbox as dermatology. We work very closely together to cover each other in these areas.

And then, another big area would be like breast hypertrophy, gynecomastia, and hand conditions, believe it or not. We do a lot with hands.

Host 1: Wow, that's a wide range.

Kelly Patterson: It sure is.

Host 1: Yeah, it's a lot. And I love that you talk about it in forms of restorative, not cosmetic. It's restorative, because our littles don't need cosmetic per se. They are beautiful just the way they are, as everybody is the way that they were created. So, I love that restorative, to get them to normalcy or to functionality. So, that's perfect.

Kelly Patterson: So true. I always say that our kids wear their diagnosis and you don't see that in a lot of other areas. So, I think that's a thing to keep in mind when we talk about it and people kind of make judgments sometimes. So, I think that's super important to keep in mind.

Yeah. Absolutely.

Yeah.

Trisha Williams (Host): Yeah.

Host 1: Very good point. What is the most common diagnoses or something that you really have a knack for that you really like to take care of?

Kelly Patterson: I love taking care of head shapes. That is my absolute most favorite thing. I feel like it's just an area where I'm really comfortable and I enjoy exploring and learning. And under that umbrella is one of the things we're going to talk about today. So, plagiocephaly and craniosynostosis are the biggest things. And then, we jokingly have our other categories, which are, "Is it due to being in the NICU or something like that?" Or when all else fails, who do you have to blame for their head shape?

Host 1: All right. Do they look like their parents, right?

Kelly Patterson: Yes, exactly. Yes. And when you get the whole genetic, you know, tree standing in front of you in a room, it's super easy to be like, "Aha!"

Host 1: Yeah. Absolutely. You look like daddy.

Kelly Patterson: Yeah. We get to pick on people all the time, which, you know...

Host 1: Absolutely. Well, one thing that we kind of want to do a deep dive into is kind of the difference between plagiocephaly versus craniosynostosis. That's something that I'm not very familiar with. And so, I would love for you to kind of take a deep dive into that with us today.

Kelly Patterson: Absolutely. And I'll tell you what, the literature doesn't make it easy. So if you look up plagiocephaly, you're going to find things about craniosynostosis. And if you look up craniosynostosis, you're going to read about plagiocephaly. And they really don't make it any easier after that, because there are types of craniosynostosis that they throw the word plagiocephaly in.

So, we try to keep it pretty clear, but the biggest thing is we are always teasing out that difference when we see a child. So, plagiocephaly, the word plagio- comes from the word for oblique head from the Greek. And then cephaly, of course, refers to the head. And then, we further divide that down into the two types, synostotic and then deformational. So, most of these are going to fit into one of these two categories or the third and fourth that we mentioned earlier.

So, I think the easiest way for me to discuss it is one is something that happened due to sort of positioning, and the other is one that happened due to the brain giving the bone a signal to close too early. So with craniosynostosis, easiest way that I can describe it is if you think of your brain sitting in a room. So, you have a ceiling, you have a floor, and you have four walls, fairly airtight in between that. And so, your brain sits in there. That's how we are as adults. Children have eight sort of natural openings in their skull, and their brain grows 200-300% in the first two to three years of life. But they do the biggest bulk in that first year.

So, what happens is, in craniosynostosis, something closed too early. The main sutures, if you kind of palpate the top of your head, and you think about where your soft spot was as a baby, or where the soft spot is, the major ones that we talk about are the metopic, which runs from the soft spot down the forehead. You have two separate coronals that run on each side, kind of around the ear, so if you think of from the soft spot down to the ear on each side. You have the main kind of large one that goes across the top of the skull, and that's called the sagittal. So if you think of it going from the soft spot to about the back of the head. And then, you have two lambdoidals that follow on each side of the back of the head, and they all close at different times. The metopic one closes at four to six months of age and the rest of them sort of close throughout the rest of your life. Sort of a fun fact I like to give people. If you were on a nature walk and you found a skull and it had a hole in the top of it, what would your guess be? And most people would say, "Oh, they were probably stabbed in the head." Well, actually, they're probably under 25, because our sagittal suture doesn't fully close until we're in our 20s.

Host 1: Wow.

Kelly Patterson: So, I mentioned you have those eight cranial bones and then you have those sutures in between. And at some time, the brain gives a signal for those to close. And it's like, when bone meets bone, because the brain growth is done, it sort of fuses shut. And craniosynostosis, that's too early. It happens too early. And with each one, you see a very specific head shape. And some of these may sound a little, I don't know, obnoxious the way I put them, but when I'm speaking to a parent, sometimes the easiest, simple explanation has the most impact.

So if a kiddo has that metopic one closed, it's typically closed at birth. And the head shape becomes like a triangle, and they almost look like a Phineas and Ferb character, if everybody remembers that, and their head almost looks like an axe handle. So, they get such a deep pinching that you could almost chop wood with their head and that sounds horrible, but that's exactly what it looks like. And then, their eyes are too close together.

Then, we have the sagittal craniosynostosis. And that one, we call it boat head. So, they have a long, narrow head. And often, their head circumference is off the charts, 100th percentile, but it's not macrocephaly. It's not a big head. It's a long head. So, they almost have an outpouching in each side. So, it looks like they're bulbed at the front and bulbed at the back. Again, one of those things you're going to pick it up at the grocery store. You're really going to notice it.

The more subtle ones come in with the coronals. And you can have a bicoronal, which means both of them shut too early. And some of the time that's due to a syndrome. They sort of look like a Peanuts character or Flat Stanley, so their face is very flat and tall. And they often have a lot of eye features. Their eyes look very big or they'll have exophthalmos. And then, you could have one closed on either side, and that's a tricky one, having a unicoronal because it takes a while to see it. So, what eventually happens is the opposite side, so let's say your right is closed, your left side, the eye is going to kind of pull back because of the way the skull is being forced to grow. And they look like they're wearing a harlequin mask and we call that the harlequin sign. And then, their face almost looks like they're living in two different planes. So, it's almost like a 2D versus a 3D on each side. And for fun, they like to call that one anterior plagiocephaly. So, that's where we get confused there. Yes, let's mess that up more than we can.

And then, the lamdoidal, the best way I can describe it as you walk in the room and you're like, " Hmm, this isn't right, but I can't figure out what it is." And when you turn the baby around and you look at their skull base, it's not even. So, one side kind of goes up like a trapezoid and it's just very, very odd-looking. And that's kind of our rarest one that we see.

Host 2: That's so interesting and I love how you described it. It's really helpful. Do we know what causes them to close like so early at birth, say the ones that you said that typically you would know right at birth?

Kelly Patterson: Right. Yeah. So, there's a lot of theories out there. You know, is it an endocrine problem? Is it due to a syndrome? But the rest of them, we just kind of say, or like any other diagnosis, you throw the coin out and that's what you got. So, we would love to know more about why this happens. And I think the best way I ever heard it explained was one of our neurosurgeons used that term of the bone gets a signal too early to close. So, lots of research going into this to figure out the why. We do know that some are genetic. We currently have a family that the father had sagittal, and they have four boys and three of the four boys have it and the youngest two are twins. So, one has it and one doesn't. So, it's really interesting. And they're doing a lot of looking into that family. We have such a robust research department at Children's. It's amazing what they're looking into.

Host 1: Wow. So, the genetic component blows my mind.

Kelly Patterson: Yes.

Host 1: As you know, research and stuff starts to come out, more and more is just going to be linked back. Because I think a lot of things, like when we were kids, it is who you are, you know? And now, we're getting into all this being able to stratify all this data and put all these things into cool microscopes and things with our research department. And it's amazing.

Kelly Patterson: It really is.

Host 1: It's so cool. With these kiddos, do you collaborate with neurosurgery? Because what I'm kind of digging back into my past career, like I remember neurosurgery does their magic and then these kids have room to grow.

Kelly Patterson: Room to grow, yeah. So, one of the things with craniosynostosis, again, timing is kind of everything. And the earlier we can get these kiddos seen and diagnosed the more options families have. So, we do work very, very closely with neurosurgery in both realms. But typically, if we get a kiddo under four months old, really, we'd love them to be under three and even two months old. And they're diagnosed with even multisuture craniosynostosis. So, some kids can have not one, but multiple closed.

There is an option for a really cool minimally invasive skull surgery, which blows my mind. We have two neurosurgeons at our institution that do it. And what they do is they use an endoscope. They go in and they basically make two incisions, one at the front of the head and one at the back of the head, and they take out that fused suture. The bone is so malleable and soft at that point, they're able to just grab it out. And then, they put some openings on either side of the skull to allow everything to grow in. Their body just recognizes it as, "Hey, I've got an opening here again, and I need to fill this in." And it's pretty cool to watch how that happens.

These kiddos that have the endoscopic or a strip procedure done have to be helmeted afterwards, which is different than the kind of helmet that we use for plagiocephaly. So, they're followed very closely. If for some reason we don't get to the kid until they're a little bit older, this is when Plastics and Neurosurgery kind of work together. So typically, if a kid doesn't get to us before four months of age, we usually save that surgery, the more open procedure for anywhere from 6 to 10 months of age, ideally. And that actually involves the plastic surgeon in the operating room who makes an ear to ear incision, which is zigzagged. So over time, their hair doesn't show where their scar was. They actually pull down the front of the face. They remove the bone that is problematic or the suture that is problematic. And then, I call it Knights of the Round Table, because the neurosurgeon actually is one that pulls off the bone. And then, they kind of sit together at the table and they take the bone and sort of almost like Jack and Jill roll down the hill, they put them back together. And so, they break the skull and they put it in different places. And then, they put it together with dissolving plates and screws. And then again, over time, the body does what it's supposed to do. Both repairs are excellent. It's just a matter of when you were diagnosed. And some people, yeah, they're early enough for the strip, but for whatever reason, they're not going to be able to do the helmeting process or whatever. So, it's really cool that we have options.

Host 2: Yeah, that is really cool. It sounds like the key is partially recognizing it early. So, I'm sure you get many kids who PCPs are like, "Okay, is this plagiocephaly or craniosynostosis?" I heard you describe those craniosynostosis. But then, tell us what the key is to recognizing that it's just plagiocephaly.

Kelly Patterson: Sure. So again, the earlier, the better with both of them. And the differences can be very subtle. Your history, we always talk about history. It can give you up to 75 to almost a 100% of your diagnosis. You're hearing those things, when they noticed it, what the symptoms are.

So plagiocephaly, like we talked about earlier, that's flathead. But they like to confuse us and call different kinds of craniosynostosis plagiocephaly as well. So when I get a kiddo, the biggest thing that I kind of do that deep dive into is the history. I want to know their birth history. How many weeks were they born at? What was noticed at birth? Because the timing of when they noticed something is pretty critical. Most of the craniosynostosis, except for like the lambdoid or the coronal, you're going to see it at birth. It's going to be noticeable right away. And it is very, very distinct. But the other kiddos, if it's a coronal or even a lambdoid, I've really got to do some thinking and knowing my right from my left and where everything should be in that process.

So, plagiocephaly, actually we've had to change our viewpoint because, again, we used to call all cranios a form of plagio. So, we've started calling it deformational plagiocephaly or positional plagiocephaly. And believe it or not, this actually can start in utero as well. So if we have a baby that's breech, mom has sort of an irregular uterus or a twin or a triplet, that's even higher risk of developing plagiocephaly. My own daughter was born with extreme right side plagiocephaly. So, it definitely can happen in that space. Then postnatally, the main cause for it is we started this in the 1990s, because we started this campaign, or the American Academy of Pediatrics did, that we put babies on their backs to sleep. I am of another generation that I was on my tummy all the time. And so, our generation has these nice round Gerber heads. But now, that we've started putting babies on their backs to sleep, we're seeing brachycephaly, which means kind of flat up the back of the head as our primary head shape these days.

Host 2: Oh, yeah. You can see kids too, right?

Kelly Patterson: You sure can.

Host 1: You see but not that we're recommending now to flip to belly. We do know that that prevents--

Kelly Patterson: Exactly. 100 percent.

Host 1: Yeah. It's just safer to safe to sleep on their back.

Kelly Patterson: Safe to Sleep. And that's what they call the campaign now.

Host 1: Yep. Safe to Sleep. So, it's kind of like that situation of, "Okay, we're going to deal with flatheads, but safe to sleep."

Kelly Patterson: Safe to sleep. And when we have parents that come to us and say, "Oh, I've tried everything. I'm using bolsters on either side, or I'm giving up and putting them on their tummy," we're like, "Oh, we can't recommend that you do that. We absolutely want your baby on the back." There's so many things that we can do to help. So, I can kind of walk you through what a typical plagio diagnosis looks like.

Host 2: That'd be great.

Kelly Patterson: Yeah. So, I probably in my clinic days see five or six flatheads. And on average, I would say 99% of them are plagiocephaly. But my kind of work wife and I have been the one to diagnose most of the cranios, because we see most of the flatheads. So typically, the story is, you know, vaginal birth or C section, I haven't really noticed a difference between either one. But the number one thing that I hear, they hate tummy time. "My baby hates tummy time. They don't want to do it. They don't like it. So, I just put them on their backs." So, that requires a lot of education.

The other thing that's interesting is you'll hear the parents say, "I noticed early on they were favoring their left side or right side." And that is kind of a sequelae of positioning as well, which the child can develop torticollis. So, we look at our story. Most of the time, babies, if they have a preference, it's going to be the right side. And the reason for that is us. If I pick up a baby, I'm right-handed. I'm going to put them in my left arm. I'm automatically causing that problem. And believe it or not, if we walk through our homes, we set up our world to live to the right. We encourage our babies to live to the right. If you think about the baby, the most important job in their life is to figure out where you are. So when you come in the room, most of them are turning right. And then, they get comfortable. And then, they get torticollis, which is neck tightening.

But the typical thing that you see with a baby with plagiocephaly, if they're flat up the back, oftentimes I know they're a really, really good sleeper, so I'll say to the parent, "Hey, your baby must be a good sleeper." "Oh, they've been sleeping 12 hours since they were two weeks old." I'm like, "Oh, okay. That's a whole 'nother thing." But great sleeper, and those are your kids that you see. And they're just flat up the back. And I think most of the time, that's the ones that I get the parents say they hate tummy time. Then, I would say probably of the 60% left, you get the right-sided more than anything.

So, the picture that you see, you don't always recognize it when you walk in the room, but you look at that bird's eye view. So if you picture, if you put your feet on the ground, and those are the ears. And you think in front of you is the forehead and then back of you is the back of the head, what you see in a right-sided plagiocephaly, the right posterior occiput is flat, their right ear is shifted anterior, and then the right side of the forehead sticks out. So, it's all on one side. It's a shift. It just shifts all forward. And so parents, what they'll say is, "Oh, the right side's flat. But man, that left side, they've got a huge bump there. I don't know what to do about this," or they think that ear is affected.

So, the goal is to kind of turn everything back, move the right side backwards is our goal with that. And then, left side, of course, is the opposite. So, the posterior left is flat, left ear is forward, left forehead sticks out. And as we discussed before with the other one, just kind of flat up the back, they truly are flat up the back. The difficult thing that comes in sometimes is their genetics or their culture. So, there are many cultures that believe in flatheads or different ethnicities that you see it more common. So, Asian descent and some Hispanic descent oftentimes already have that as part of them.

Host 1: So, would the recommendations be these are the kiddos that you helmet then, right?

Kelly Patterson: Yeah, that's a big thing. And in our group of providers, we are split. We sit in two different camps, or actually kind of three different camps. One is pro-helmet, two is no helmet, and three is I really don't think they're going to do anything, but if the parent feels like it's working, then it's great.

So, I always preface when I'm with a family, my daughter had a helmet 20 years ago. At that time, it was life-saving for me because I had an 18-month-old child, I had a child that refused to stay off her right side, and I had a dying mother in my home. So for me, that was a tool that I could use to help keep her off the back of her head. And you hear that all the time with families, they've got other children, they have many of our kids, they've got other kids that have things going on. And baby number two or baby number four has to ride along in the car seat a lot, and we see that from that. So helmeting, I kind of talk to people about, I call it Kelly's rule of fives. And that is, if I had ten kids, all the same, perfect science experiment, I put five in a helmet, five not, at age five, would the general population know who had a helmet? No. Would I know who had a helmet? Probably not. And that's the beauty is once you remove that roadblock, say from them being on the right side or the left side or off their back, their brain is going to continue to push that skull and round it out. What a helmet does is gets you there from point A to point B much faster. It's like braces, braces for the teeth. It's not necessarily putting any force on the skull, but it's allowing areas to fill in where they need to fill in. So, helmets are used for that purpose. They're not actually doing something intentional or forceful to the skull.

Host 2: That's really interesting. I love the way you described that. And I didn't know that. You know, I definitely thought that it did something to the skull to try to help even it out. So, that's really interesting. So, a lot of times, it sounds like when kids get helmets, it really just kind of like potentially speeds the rounding of the head out just a little bit by a little bit of time.

Kelly Patterson: Exactly. So, what it does is takes advantage of that big growth spurt that they have and it just harnesses that power. So, the earlier you can get it on, so typically the earliest you would ever kind of refer a kid for a helmet would be like four months, but the earlier the better. So most kiddos, if they can get their helmeting process started by six months of age, the average time is about three to six months, but I feel like people kind of settle in around four months is what it seems to be. They do wear it 23 hours a day. They break into it slowly over the process.

And the biggest complaint that I had about my daughter's helmet was that she got very brave. And so, she would do things to catch up with her brother, because it didn't hurt when she hit her head. So, she got really smart. And then, they also don't like it when you take them off, because they feel like you're taking off the top of their head. And they kind of look at you like, "Wait a minute, I've had this my whole life and now you're taking it away from me." So, it is kind of funny to see how they work. They are expensive if you have to pay for them out of pocket, and insurance is so fickle. You never know if they're gonna pay for it. So, my speech to a parent goes something along the lines of, "Do you have to do this?" "No." And I give them my kind of my rule of fives. I tell them what it will offer. And then, we walk through the process, which is if your insurance company has a piece that says we do not cover cranial remolding orthosis, they're out of luck and they're going to have to pay out of pocket. There's a couple of different places that do it, but average price is a couple of grand. So, you got to think about your healthcare dollar. And when I think of families that are already struggling with having a newborn or twins or whatever, we know how expensive that can be. I'll really encourage a family at that point to not spend their healthcare dollar on that, because there's so many other things they can be doing to correct the shape naturally. They're just not going to see it as fast.

Host 1: I feel like we could sit here for hours and hours and hours and talk about this. It's fascinating.

Kelly Patterson: For sure it is. Yeah. Yeah.

Host 1: You are so knowledgeable. I'm going to kind of throw you an off the cuff question here. I would love for you to give like our primary care providers-- we have a lot of nurse practitioner students that like to listen in, what would be just some quick advice when we're looking at a head that they can really grasp onto and take home?

Kelly Patterson: Absolutely. So when they notice it, or a parent notices it, you're seeing your pediatrician as the parent of a child in that first year of what, like 10 times, I think it is. And so when you're going in those initial visits, pretty much most parents have picked this up by one to two months of age. If we could have pediatricians recognize the earlier, the better. And that kind of comes into diagnosing craniosynostosis as well too. Because like I said, a lot of these are billed as plagio, and I'm like, "Eh, I don't think so. I think we've got something else going on here." That early, early time is everything.

And in the case of plagiocephaly, if the kiddo has a right side or a left side, physical therapy is the bomb. If they can get into physical therapy and also be doing range of motion exercises, releasing that torticollis, is going to bring everything straighter faster, because all a baby knows is, "My right side feels good. I don't want to move to my left. So, I'll continue to go to my right," where we would spend the entire day working out our neck, taking ibuprofen. So, the biggest thing for me is either get them into us early, get them into physical therapy early, and really encourage the parents, tummy time, tummy time, tummy time. And I know they do ad nauseam. I wish there was a better way or some great invention. But I always stress with parents that that's such a foundation for crawling and for all the other things they're going to do in their life. So, early intervention, early recognition is key.

Host 2: Yeah, that's so helpful. Thank you so much, Kelly. We really appreciate you coming on and talking about this topic. Definitely, I think that some things have changed in the time since I practiced in primary care, so I think it's helpful to hear all of this.

Kelly Patterson: Agree. And, you know, it's taken me a while to come along in my practice too, because as a mama, when my daughter had it and I was offered the helmet, I could not see how it would get better without one. But now, that I've been doing this for years and I see the kids come through, I realize, you know what? We all kind of even out by age five. And that's the best part.

Host 1: Yeah, that would be the best part, seeing them, you know, knowing that by the age of five, Kelly's rule of five, they all even out. So, that's pretty great.

Kelly Patterson: Yup.

Host 1: Wonderful.

Host 2: Kelly, as we close things out today, we ask each of our guests on our podcast the same question and it changes by season. So, this season, the question is, what would your younger self high five you for now?

Kelly Patterson: Oh, my goodness. Going back to school. That's a no-brainer. That was something I wanted to do for a very long time and life didn't let me. But boy, she would be so proud of me now. And that makes me smile.

Host 2: That's awesome.

Host 1: That is awesome. You're a great asset to Children's Mercy, have and always will be. And I bet Plastic Surgery is so grateful to have you. So, thank you so much for coming on to our

Kelly Patterson: Thank you both of you very much. I absolutely enjoyed it. It was much easier than I thought it would be.

Host 2: We loved having, yes. Again, thank you so much for coming on.

Kelly Patterson: Welcome. Absolutely.

Host 2: If you have a topic that you would like to hear about, or you're interested in being a guest, you can email us at tdobrien@cmh.edu or twilliams@cmh.edu. Once again, thanks so much for listening to the Advanced Practice Perspectives Podcast.