Dr. Rob Steele (Host): Welcome to Pediatrics in Practice, a CME podcast. I'm your host, Dr. Rob Steele, Executive Vice President and Chief Strategy and Innovation Officer at Children's Mercy Kansas City. Before we introduce our guest, I wanted to remind you to claim your CME credits after listening to today's episode. You can do so by visiting cmkc.link/cmepodcast, and then just click the Claim CME button.

Today, we are joined by Dr. Jiang to talk about plagiocephaly prevention and treatment. Dr. Jiang joined Children's Mercy Kansas City in 2009, where he currently serves as the Division Director of Plastic and Reconstructive Surgery, as well as the Director of the Frederick J. McCoy Cleft Palate Clinic. He completed his residency in Plastic Surgery at the University of Rochester Strong Memorial Hospital, followed by a fellowship in Craniofacial Surgery at Children's Hospital of Pittsburgh. Dr. Jiang's areas of interest include cleft lip and palate, facial injuries, hemangiomas, skin cancer and vascular malformations. Dr. Jiang, thank you so much for joining us today.

Dr. Shao Jiang: It is my pleasure.

Host: So, learning a little bit more about you. It seems that you are in high demand as a speaker around the world. I see you've made your way to Dubai and to Taiwan. As we get into your expertise on plagiocephaly, do you have any tips for traveling halfway across the world?

Dr. Shao Jiang: I think the most important thing is to stay hydrated when you travel, because you spend 10, 12 hours in the airplane in a pressurized environment, you don't realize you get dehydrated. So, it's the most important thing, is to stay hydrated. And then, I always adjust my watch before I start to fly, just to get into the mindset of the local time zone.

Host: Yeah, okay. Didn't think we'd get that kind of advice this time, but I think that's a good one. Let's jump right into it. For our listeners, we've got a lot of primary care pediatricians that are listening in. So, why don't we just start, basically, and talk about plagiocephaly, and just what is plagiocephaly in and of itself, and maybe how common is it?

Dr. Shao Jiang: So, plagiocephaly is a very broad term. It describes a condition where the skull is flattened or abnormally shaped in an infant. It is actually extraordinarily common. One out of seven babies born today have this particular challenge. The incidence of plagiocephaly has really increased after the pediatric society advocated for Back to Sleep campaign. And since then, there has been increased number or percentage of the population that have plagiocephaly. So, it is quite a common condition. In Plastics division, we see on average between 20 to 30 patients a week with this condition.

Host: Certainly in my practice, I can remember when the Back To Sleep campaign kind of got put in and you started to see a lot of those babies with flattened occipital area. So, we're going to get into some of the treatments for plagiocephaly in a little bit, but maybe you could touch on some of the potentially common ways in which one could mitigate or prevent to some degree plagiocephaly, given the fact that there is a safety issue in having those babies on their backs.

Dr. Shao Jiang: So, we always advocate to back to sleep. So, we cannot change the sleep position of an infant. We do, however, advocate for spending adequate amount of tummy time in a supervised environment. So, that's important.

The other thing that's important from a management perspective is the early diagnosis of torticollis. Torticollis, which is muscle imbalance for the sternocleidomastoid muscle in the neck, is probably one of the most significant contributors for plagiocephaly. In my practice, we see these type of conditions go hand in hand quite a bit. So if you imagine that the infant has a tight neck muscle and therefore cannot turn the head equally to both sides and develops a persistent sleep position and, hence, the development of flatness in the back of the head.

So, I think early recognition of torticollis and adequate treatment, such as referral to a pediatric physical therapist or occupational therapist, wherever you may be, is very important. And then, secondarily, the amount of tummy time that infant spends.

Now, the question I always get is, "Well, my baby does not like to be on the tummy." When my son was an infant, he did not like to be on his tummy either, but they get used to it. So, incrementally increased amount of time that one spends on their tummy can be implemented as a repositioning strategy for the parents.

Host: Yeah. Very good. That's great advice. I want to pull the string a little bit on the torticollis. You know, my experience was that you typically would see that very shortly after birth. But is that what you see? Do you see torticollis actually presenting, potentially causing plagiocephaly a lot later? And maybe you could also give us a flavor of when do you typically see these patients present?

Dr. Shao Jiang: So, in our practice, the referral typically comes in somewhere between four to six months of age. And I would say that an overwhelming majority of the time, parents know that the kid can't turn both ways equally prior to that. So, they will often describe a situation where, "I put my baby down in the crib, and he or she preferred to turn to the right." Right side, by the way, is the most common side. "Then, I try to shift the head to the other side, but five seconds later, they're flopped back to the same side." It's almost as if there's a loaded spring or a rubber band that's pulling them that way. It's a very common description of torticollis. So, parents recognize it quite early, and I think a lot of the pediatricians recognize it as well. So, I would say that typical diagnosis of torticollis should be made prior to three months of age, and therefore adequate therapy can take place between three to six months of age if one were to avoid progression of the plagiocephaly.

Host: Oh, that's great advice. Let me shift a little bit and talk about maybe the different types of plagiocephaly. We're talking a little bit positional, but are there others that we should keep in mind?

Dr. Shao Jiang: So, abnormal head shape is categorized either as deformational, which means there's an external force that's causing the flatness, or craniosynostotic, which means there's an inherent pathology as a premature fusion of the growth plate. So, I think most of us are concerned about the differentiation between deformational plagiocephaly versus others.

The way that I typically tell the parents or tell the pediatrician when I engage the community pediatrician is to look at the head shape. If the forehead on the side of the flatness is forward, meaning that if the baby has flatness on the right side of the occiput, and the right forehead is forward, that's usually a good sign that this is deformational or positional plagiocephaly. However, if they cannot see any forehead change or in fact the forehead is pulled back, that's a bit more concerning for other causes.

Host: That is really great advice. I'd never heard that physical examination pearl of wisdom. So, that's a really good one. Tell me, what are the more common causes? You've mentioned positional for craniosynostosis. But if there are any others, you can let us know that. But then also, what is the advice for the pediatrician about when to refer? At what point do you go, okay, we're having some trouble here and we need to send them to someone like yourself?

Dr. Shao Jiang: The way that I typically tell the pediatrician about the differentiating factor between the deformational plagiocephaly or positional versus craniosynostosis is if you think of deformational plagiocephaly as a parallelogram, if you draw a parallelogram, everything is shifted on the same side, in one direction. Whereas if you think about craniosynostosis as a trapezoid, so things are moving in opposite directions. And those are probably the two most common cause of abnormal head shape in children, either deformational or craniosynostotic. And the deformational or the positional plagiocephaly could occur on one side, left or right, right side being the most common, or both sides if the baby has no preference or no torticollis, it's just strong preference to sleep on their back straight, looking straight up.

You see sometimes in patients with other congenital abnormalities such as Down syndrome or motor developmental delay that the babies do not sit up in time or do not roll over in time. The best time for the pediatrician to refer these patients to us will be somewhere between four to six months of age. And the reason for that is, when we assess them at around four months of age, if there is a question for craniosynostosis, our talented neurosurgeons here can do minimal invasive surgery for these patients to correct that particular problem. Three to four months, that's the window for a minimal invasive surgical correction for abnormal head shape.

Now, overwhelming majority of the time, it's going to be positional changes. And in that regard, if there's not been a significant intervention from a physical or occupational therapy perspective, then we can advocate for that and get some specialized therapy in place. Now by six months, we should see these kids, because between six months and 10 months, the brain grows really rapidly. And if we were to use any molding device, such as a cranial molding helmet to correct the head shape, we want to utilize the expansile force of the growing brain to push that flatness out. And that between six to ten months is when the helmet has the best chance of doing that. So therefore, we want to see the kid before six months of age.

Host: Very helpful. You've now started to touch on the common treatment plagiocephaly. And you've mentioned a little bit about the helmet. Maybe you could go into some more detail, with respect to just all the treatment options once plagiocephaly has been identified.

Dr. Shao Jiang: Typically, we see the patients and I would say that I categorize patients according to minimal, mild, moderate, or severe. That skill is rated for if there is any facial difference, meaning that the flatness in the back of the head is causing the front of the face to change. So if there's no facial changes, then typically they're in the mild or the minimal category. Once you see facial changes, such as the orbit starting to shift superiorly or the ear position starting to change quite a bit, then we're in the moderate category. The helmet is really a passive device, meaning that it's not actively squeezing the head into shape. It's almost as if I don't know if you've ever seen in your travels, in Japan, they grow this watermelon that's square, perfectly square.

Host: Oh yeah, I've seen those. They're cute.

Dr. Shao Jiang: Yeah. Yeah, the watermelon. Right, right, right. And it's amazing because you could slice them and they come out to be like these square pieces. It's very interesting. And the way they grow that is by growing watermelon in a square box and then change the size of the box as the watermelon grows. Well, helmet sort of works on the same principle in that the head size has to change in order to sort of correct the shape. So, between 6 to 10 months is when the brain really grows fast and that internal growth pushes the flatness into the shape of the helmet. And the orthotist that manages the helmet then shaved down the helmet in the area of flatness to accommodate the growth, thus changing the flatness in the back.

Host: And what that has also taught me is that all the references to a head as a melon are actually pretty appropriate, based on what you're saying. So, let me skip back to the sort of the minimum to the moderate. What can you do with physical therapy versus what's not going to fix the problem and you really have to move to a helmet? Where's the decision process there?

Dr. Shao Jiang: So, the decision process is hopefully at six months, we have laid eyes on the infant twice, once between four months of age, and then having them return to clinic after completion of physical therapy, after the resolution of torticollis, at around six months of age, to take a look at their face.

Now, at that point, then, I typically give the parents the option of treatment. Some parents are extraordinarily concerned about the appearance of the baby's skull. Whereas others, knowing that this is essentially a cosmetic problem, not a functional problem, are less concerned. And I give the parents a choice of whether they wish to proceed with helmet therapy or not. It's always the parent's choice, by the way. The plagiocephaly does not cause any functional deficit.

The flip side is not true. Functional deficits sometimes could cause plagiocephaly. As we talked about earlier, if you have developmental delay or motor issues, or the kids that have hip dysplasia has to be embraced and they can't roll over in a timely manner, those conditions can contribute to plagiocephaly. But plagiocephaly does not contribute to developmental delay. So, it's never a functional problem.

Host: And one last question, I don't know how you've experienced or what the feedback you've gotten with patients. But, as you mentioned, plagiocephaly in and of itself is not going to necessarily cause functional problems. And because of that, that has sometimes been an excuse on payer's side to not pay for helmets and whatnot. Do you have a sense from the parents if that's gotten better?

Dr. Shao Jiang: Yes and no. Some parents have gotten better as far as compensation for helmets. Now, if there is a co-diagnosis of torticollis, if despite resolution of torticollis and course of physical therapy, the head shape did not improve. And if based on measurement, the magic number is sometimes the payers are looking for is 10 millimeters or greater, meaning 10 millimeters or greater in cranial difference, then sometimes they're more lenient on coverage for the payment for the helmet.

Host: Very good. Dr. Jiang, Thank you so much for your time. I think we've learned quite a bit through this, relatively brief podcast. But before I let you go, I have to ask, are you going halfway across the world anytime soon?

Dr. Shao Jiang: Not anytime soon, but we just got back from Japan for a family vacation.

Host: And everyone stayed hydrated, I presume.

Dr. Shao Jiang: Everyone stayed hydrated. That's right. Absolutely.

Host: Very good. Well, thank you again Dr. Jiang, for joining us today. As a reminder, claim your CME credit for listening to today's show, and go to cmkc.link/cmepodcast, and then click the Claim CME button. This has been another episode of Pediatrics in Practice, a CME Podcast. See you next time.