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Sybill Naidoo PhD, RN, CPNP (Guest): Hi. I'm Dr. Sybill Naidoo. Certified pediatric nurse practitioner and a mom doc at St. Louis Children’s Hospital.

Melanie Cole, MS (Host): Welcome. This is Mom Docs, the podcast from St. Louis Children’s Hospital. I'm Melanie Cole and today we’re talking about plagiocephaly, or misshapen head in babies. My guest is here with us. So Dr. Naidoo, what is plagiocephaly? What is the misshapen head in a baby?

Dr. Naidoo: Plagiocephaly is flattening of the head in an infant, typically seen within the first couple months of life. It can either be present at birth, which is typically from either being a multiple or the birth process itself, or it can be present after the baby is born. That is typically due to external forces such as sleeping position or devices that the baby is placed in.

Host: Is it something the parents would notice Dr. Naidoo? Would we notice that the baby’s head is getting a little flatter? Does it happen kind of slowly over time?

Dr. Naidoo: If it’s not present at birth, it usually happens in the first couple weeks of life. Most parents do notice it. Sometimes it is pointed out by the pediatrician, but typically parents do start to notice it within the first, I would say, two to six weeks of life.

Host: So I’d like to ask you if there’s anything parents can do from birth to prevent this. However, and I'm asking that question, but we’re told to put baby to sleep on their backs. Does that contribute a little to that flat head on the back? We know we’re supposed to do that.

Dr. Naidoo: Those are all great questions. Back sleeping does contribute, but I don’t think it’s the only cause of deformational plagiocephaly. I think it’s just one of the factors. So since we started the Back to Sleep campaign in 1994—which is now known as Safe to Sleep—it was recommended that babies sleep on their backs. During that time, a lot of other devices have come out. Like travel systems. So you have a car seat that will go from your car into a grocery cart, and then it snaps into a stroller. Then it can go back into your car where you don’t have to take the baby out much. You can go into a restaurant, baby still in the car seat. That’s a contributing factor. Lots of devices at home that parents have, like a swing, a mamaRoo. Rock and plays were always a big contributing factor. However, they were just recalled. So parents should not be using those for any reason any more. So that was another contributing factor.

Another thing is tummy time. Babies are not doing nearly enough tummy time. We frequently hear baby doesn’t like spending time on their belly, so we don’t do it. Or we do five minutes a day. By four months of age, a baby should be doing about an hour of cumulative tummy time every day. If parents start early, when they first bring the baby home, they can do a minute of tummy time. That’s great. You’ve got to start it early. If you don’t put the baby on their belly until they’re two or three months old, they do hate it and it is miserable for everybody. Just getting in that habit from day one of short brief periods of tummy time. The baby does not have head control at that time, and we realize that, but if you're putting them on a soft surface and they're observed—This is while the baby is awake, of course. The babies are much more tolerant of tummy time. Things kind of cumulatively contribute to the baby’s head getting flat.

Host: That’s great information. So then tell us a little bit about how the staff at St. Louis Children's Hospital determine whether or not a baby needs a helmet. We’ve seen those little babies at the grocery store. They're wearing those little helmets. You kind of wonder as a parent, why are they wearing that? What is it doing for them? Speak a little bit about helmet therapy.

Dr. Naidoo: Sure, sure. When the child comes in to see us, the first thing we’re gonna do is rule out a more serious diagnosis called craniosynostosis. It’s a completely different diagnosis. If a baby has that, it’s present from birth. It’s also an abnormally shaped head, but that requires surgery to correct it. So first and foremost we want to make sure that that is not what the baby has. Once that is ruled out by physical exam and any diagnostic imaging if needed, then we kind of evaluate several factors. How old is the baby? What have parents done so far to try to make changes in the head shape? Are parents seeing any changes in the head shape? We also have physical therapy in our clinic. Our patients are all evaluated by a pediatric physical therapist that also works here at St. Louis Children's.

We’re looking for neck tightness. Another diagnoses that goes hand and hand with deformational plagiocephaly is torticollis or tight neck muscles. So baby doesn’t have a full range of motion of their neck. As you can imagine, that would also contribute to the head getting flat. So if baby’s neck doesn’t turn all the way to one side or the other, they're kind of stuck or trapped on one side which causes further flattening of their head.

So, for example, if we see a baby that is six months old and parents say, “Gosh. We have been trying all of this stuff for the last few months. We’ve been getting the baby on their belly more. We’ve been getting them upright more. We are not seeing improvement.” In that situation, we would discuss helmet therapy. The helmet works by fitting closely over the wider parts of the head, and then it builds space in where the baby is flat. So it’s redirecting the growth of the skull and filling in where the baby is flat. It doesn’t hurt the baby. It doesn’t squeeze their head. It doesn’t cause headaches. The baby’s actually adjust very quickly, usually about a day or two. They do sleep in it. They're in it for three to six months duration and about 22 hours out of the day. So pretty well all the time.

They’re seen on a monthly basis by a certified orthotist. An orthotist is someone who also makes splints and braces. In the St. Louis area, we work closely with a local orthotics lab with trained cranial orthotists. Outside of the St. Louis area, we do have a list of places we can refer you to that also have trained cranial orthotists. So the families aren’t frequently traveling up here for adjustments to the helmet.

Kind of going back to how we determine who gets a helmet. If we see a baby maybe that’s four months old, they’re not too flat and parents say, “Gosh I haven’t really tried anything.” I want to give it a little bit longer. I want to try some of those things first. Typically what we do is give the parent lots of suggestions of things that they can try at home. Then we’ll see them back in about four to six weeks and see what kind of progress they're making. If baby is doing well when we see them back, great. I think they're on the right track. If they come back in six weeks and parents say, “We have pulled out all the stops. We’re doing everything we can, and the head shape’s still the same.” Then we can talk about helmeting at that time. Helmeting is always up to the parents though. We never tell anyone you have to use the helmet. There are families that say, “We are not interested in it.” That’s absolutely fine.

Host: Can they ever take it off during the day or the night or bath time? Any of those things. You said about 22 hours a day or so. When do we get to take that helmet off?

Dr. Naidoo: Right, right. So the helmet comes off when the baby gets a bath every day. They need to have their head washed even they're not getting a whole bath just because they do get kind of sweaty in them. So they need their head washed every day. Then we have them take it off a couple times during the day, wipe out the inside of the helmet just to keep it clean, and also to look at their skin and make sure their skin looks healthy and they don’t have any red spots anywhere.

Host: How do you know if it’s working, Dr. Naidoo? How can you tell if it is working and it’s something that’s going to be permanent?

Dr. Naidoo: Great. So babies grow the quickest when they are first born. So if you look at the rate of growth, in the first few months of life, they are growing the quickest. As they approach a year of age, that growth slows down. Not only in their head, but their whole body. So we like to start early. Like I said in that four to six month window. Babies are still growing very quickly at that point, but not so quickly they're going to outgrow it. So you can usually see change in the baby’s head, parents can see it by looking at them. Within the first month, they’ll start to see that improvement. So typically when the baby’s in the helmet, you're going to see the most change in the first couple of months that they're in it. Towards the end, that change is going to start to slow down just because their growth is starting to slow down. So you can see change by the orthotist or by myself taking measurements, or honestly just looking at the baby you can usually see a good amount of improvement.

Host: Then how long does it take? What’s the final result?

Dr. Naidoo: Most of the babies are in the helmet for about four to six months duration. Or three to six months kind of depending on their severity level. They're going in monthly for checkups. Once the baby comes out of the helmet, they're usually in about that eight to twelve month range. By that time, babies with typical growth and development are sitting up. They’re no longer spending long periods of time in a swing or a bouncer chair or anything that reclines them. The skull bones are also getting harder at that age. So we’re not dealing with that very soft skull like we have in a newborn. So all those factors together—baby is upright more, the skull is getting harder, they don’t want to be on their backs anymore—those all contribute to the lasting effect of the helmet therapy. So once they come out, they're going to maintain that head shape. Or they may even get a little bit better in the next few months after they come out.

Host: What great information. Such an interesting topic. Dr. Naidoo, wrap it up for us. What would you like parents listening to take home from this podcast as the message about helmet therapy, plagiocephaly, that misshapen head? What do you want them to know?

Dr. Naidoo: What I would like parents to take one from this is start the positioning early. So put your baby on their bellies for that supervised, awake tummy time from very early on. Just starting with a couple of minutes at a time. Don’t leave the baby in any kind of contained device, like a swing, for long periods. They shouldn’t be napping in any of these devices. Safe sleep states baby should be sleeping in a crib on their back with nothing else in the bed. So no swing sleeping, no bouncer chair sleeping, no car seat sleeping. Those things also contribute to the head getting flat. I'm a big fan of baby wearing. So using some kind of baby carrier or sling or wrap that’s all age appropriate for the baby. Getting them off the back of their head in any way that you can.

If you do start to see that the head is getting flat, bring it up with your pediatrician. You can come in and see us. We do not require that families have a referral from their pediatrician to schedule an appointment. Another piece of advice is come early. Don’t wait until the baby is nine months old. If you’re a little bit unsure, come see us. We can take a look and let you know what we think. If you're waiting until the baby is nine or ten months old thinking it will get better, it may, but if it doesn’t that’s really almost too late to do anything at that age. So preventative things are getting the baby up and off the back of the head, early on tummy time. If you have concerns, come early. Come at three or four months so we can get some of these things in place for you.

Host: Thank you so much Dr. Naidoo for great information. I know it’s something that parents really worry about when they see it start happening. So thank you again for sharing your expertise. If you found this podcast informative, please share on your social media and be sure to check out all the other helpful podcasts in our library. Head on over to the website at stlouischildern.org to get connected with one of our providers. Until next time, I'm Melanie Cole for Mom Docs with St. Louis Children's Hospital. Thanks for listening.