Transcription:
Understanding Flat Head Syndrome in Babies and How to Treat It

Prakash Chandran (Host):  Welcome to Live Greater, a health and wellness podcast brought to you by the University of Maryland Medical System. We put knowledge and care within reach, so you have everything you need to live your life to the fullest. This episode is sponsored by the University of Maryland Rehabilitation Network. Offering a full range of physical rehabilitation services, the UM Rehab Network brings together a committed team of experts from across Maryland to help patients recover from illness or injury, such as stroke, joint replacement, or traumatic injury. University of Maryland Rehabilitation Network, bringing world-class comprehensive rehabilitation services directly to your neighborhood.

Today's topic is rehabilitation for pediatric conditions of the head and neck specifically focused on torticollis and plagiocephaly. I'm Prakash Chandran. And our first guest is Nicole Sanchez, who is currently the Senior Physical Therapist at Mount Washington Pediatric Hospital, where she serves as the Co-Lead for Infant Toddler Programming, and is the Primary Physical Therapist for Developmental Evaluation Clinic and the Torticollis and Plagiocephaly Clinic.

Joining us as well is Dorothy Cook, who is currently the Senior Occupational Therapist at Mount Washington Pediatric Hospital, where she also serves as the Co-Lead for Infant Toddler Programming. And is the Primary Occupational Therapist for the hospital's Making Value Progress or MVP Developmental Clinic. Nicole and Dorothy, it is great to have you here today. Nicole, I wanted to get started with you. What exactly is torticollis and why does it occur?

Nicole Sanchez (Guest): So, torticollis is a condition that occurs when neck muscles will contract or tighten causing an infant's head to twist or turn or tilt to one side. Typically, when we talk about torticollis, it's either classified as a congenital condition, meaning that it's present at birth or an acquired condition that can occur after birth sometime during infancy. Some causes of congenital torticollis would include positioning in the uterus, such as crowded or restricted space, a breech presentation and it can also occur as a result of a difficult birthing process. Sometimes the use of forceps or vacuum assist is needed during delivery. And in these cases, there can be an injury to a muscle in the neck called the sternocleidomastoid muscle or the SCM muscle.

And when that injury occurs, as the muscle heals, scar tissue can develop, which causes that muscle to become tight and shortened, and it will pull the infant's head to one side. This congenital torticollis is fairly common occurring in about one in 300 births. Now acquired torticollis, like I said, can occur after birth and there's a wide range of causes for this. Some of them will include Back to Sleep practices, positional head turn preferences of the infant, gastroesophageal reflux disease, visual problems, any abnormalities in the cervical spine. And often what we see here at Mount Washington, is that our infants will develop torticollis due to prolonged hospitalization and complex medical histories.

Host: Okay, well, thank you so much for that comprehensive answer. I've also heard of plagiocephaly before. I'm curious to what that is and why it occurs.

Nicole: Yes, plagiocephaly definitely is a common condition that occurs when there is one or more areas of flatness on an infant's skull and it results in an asymmetrical or an atypical head shape. So, plagiocephaly not only is associated with flattening of the skull, but it can also be accompanied by facial asymmetry, misalignment, or shifting of the ears and the eyes and bulging of the forehead on one side.

So, you can imagine that this can be especially common in newborns because their skulls are soft and malleable. And they're cranial sutures are open, which allows for shifting of the cranial bones to occur when any forces are placed upon them. Since the inception of the Back to Sleep campaign that was introduced in the early nineties, we've seen significant increases in plagiocephaly. And also because of the overuse of infant convenience devices, such as car seats, bouncy seats, and swings. Some other common causes of plagiocephaly may include positioning in the womb, especially in cases of breech presentation, multiple, twin gestations, the presence of congenital torticollis and prematurity and prolonged hospitalizations.

Host: You know, one of the things that I wanted to clarify a little bit is you mentioned the Back to Sleep campaign, being a cause for plagiocephaly. What exactly was that?

Nicole: The Back to Sleep campaign was introduced in the early nineties and it was a campaign to encourage all parents to place their infants on their backs to sleep, to prevent SIDS or sudden infant death syndrome.

Dorothy Cook (Guest): I just wanted to add that our hospital is very supportive of the Back to Sleep campaign and it's definitely the safest way to put your child to sleep. It's just something that we've noticed is an increase in these head shape changes. And we say that really just to support parents, you know, sometimes parents are really concerned that they've done something wrong that's resulted in a flattening on their infant's head and they have not done anything wrong. We're here to help and Nicole is going to talk further about that. But Back to Sleep is definitely the safest way to position your infant for sleep. And there are plenty of ways that we can address head shape, while still doing Back to Sleep programming.

Host: Okay. That makes a lot of sense. So, you talked about head shape or the flatness on an infant's skull. I'm curious, Nicole, if you could tell us a little bit more about the different types of head shape abnormalities.

Nicole: Yes. So, there are three common head shape abnormalities that we see in infants. The first and the most common is plagiocephaly. So, this is when we have flattening occurring on one side of the head causing the head to take on a parallelogram shape, when you look down from a bird's eye view. So let's say the infant would present with flattening on the posterior right side of the head, then we would also see a shifting of the cranial bones on the right side of the head pushing the face forward. So, we would also see bulging of the forehead on the right. We would see misalignment of the ear or shifting forward of the ear on the right side. A lot of times we also see fullness of the cheek on that right side.

So, this is like I said, the most common head shape abnormality that we see. And it's often seen with infants that have congenital torticollis or infants that have positional head turn preferences. The second type of cranial asymmetry we see is called brachycephaly. And this is when flattening occurs uniformly across the back of the head, causing the head to appear wider and shorter. So, this type of cranial asymmetry occurs in infants who spend too much time on their backs without alternating tummy time for play. And the third and final type of head shape abnormality is called scaphocephaly. This flattening occurs on both sides of the head causing the head to take on a long narrow, skinny head shape from front to back. Is commonly seen in premature infants or infants who have had prolonged hospitalizations in NICUs or PICUs.

Host: Okay. Great. So, you talked about these three different head shape abnormalities, and if I could just kind of summarize it back, you said it was plagiocephaly and that's the most common type and that's kind of on the posterior right-hand side. You said brachycephaly. Right? And that's when it's wider and shorter across the back. And that might be too much time on the back without alternating back and forth with playtime. And then, scaphocephaly and that's flattening on both sides, making a long and narrow head shape. Is that correct?

Nicole: Yes. Plagiocephaly though can occur on either the right or left side. The key is that we typically see more flattening just on one side of the head.

Host: Okay. Understood. So, let's talk about the different treatment options for addressing torticollis and plagiocephaly and some of the other head shape abnormalities that you were speaking about.

Nicole: Yes. So, early detection and early intervention will definitely yield the best outcomes. So, it's really important for parents to contact their pediatricians and take action in the first few months of life if they have concerns about torticollis or plagiocephaly. And typically once a pediatrician makes a diagnosis, they will often make a referral to physical therapy so that we can begin conservative treatment measures.

And these measures will focus on gentle stretching, tummy time, and developmental play and positioning to increase neck and core strength. We also focused on teaching the parents handling and repositioning techniques and also teaching them environmental modifications that would help to improve their infants head shape and torticollis. And then finally helmet therapy is recommended for cases of moderate to severe plagiocephaly that don't improve with conservative treatment measures. So, the great news is, is that physical therapy in combination with helmet therapy are very successful in improving torticollis and correcting plagiocephaly.

Host: Okay, understood. Yeah. You know, I was out for lunch the other day and I saw just the cutest kid wearing the helmet and I see it every once in a while. And some of them even have these custom helmets that they're wearing. So, I'd love for you to talk a little bit more about what helmet therapy is and how it works.

Nicole: Helmet therapy is use of a cranial helmet and they're sometimes called a cranial band or a cranial orthotic. But what it is the helmet is used to treat or correct the most moderate to severe cases of plagiocephaly and how it works, it captures and redirects growth of the infant's head into a more natural shape over time. Each helmet is custom made and custom fitted for each infant's unique head shape, and it requires frequent adjustments, to allow for growth in the flattened regions of the head. It's typically worn for about 23 hours a day, and most babies will adjust very quickly to wearing the helmet without any pain or any impacts on their physical activities or play skills. And on average, the treatment time is about three months, but this will surely depend on your child's age and severity of their plagiocephaly.

Host: Now, Dorothy, I want to actually shift over to you. You know, we now have a good understanding of the different types of head shape abnormalities, but I'm curious as to how Mountain Washington Pediatric Hospital works to prevent or treat torticollis and plagiocephaly in infants who have been hospitalized.

Dorothy Cook (Guest): Sure. So, the great news is that as Nicole was sharing with us, there's a wide variety of treatment options. As you said here at Mount Washington, we do work to prevent it even before it starts as well. There's a large team of specialists that work with our little guys, our smallest patients, and head shape and posture are on our minds right from the start. Physical Therapy and Occupational Therapy will take the lead in assessing the child's posture and head shape. And what we'll do is work in conjunction with the doctor to make sure that we have a plan of care in place specific to the infant that will help manage their needs. Medicine, therapy, nursing, and also our child life and therapeutic recreational staff will all work to participate in the day to day management of the infant's position, which will affect their posture and their head shape.

At the beginning, we primarily try to focus on the positioning of the baby in order to prevent any of these head shape anomalies from occurring. But as Nicole mentioned, some of them are already present at birth. And sometimes the patient will be very medically complex and really need to be in a certain position. And at that point we really need to take care of their medical concerns and keep them stable and keep them comfortable. And if that results in, you know, some head shape issues, then we can address that afterwards when the patient is more stable. So, we focus first on positioning. We can use positioning equipment as needed specific to the child and their case.

And then what we'd like to do here, is really work hard with the parents to make sure that everybody is on the same page and that we have a good followup plan ready for the patient when they discharge, so that the caregivers feel comfortable with what to do at home and should the child need any further assistance, we can work on that and get those needs met in the community as well.

Host: Yeah. So, you just mentioned the followup plan. I'd love for you to expand a little bit more on what that looks like after hospitalization.

Dorothy: Sure. This is something that's really on our team's mind from the get go, because at Mount Washington, the children are here to make a little bit more progress from wherever they were born before they get home. So, we're really concerned with the discharge planning and making sure that caregivers feel confident with that. What we always recommend for our babies who've been hospitalized is that they follow up with the Infants and Toddlers Program after discharge. And that's a really wonderful free and statewide program that supports infants and toddlers in the home. So, that's a wonderful service that allows for really accessible therapy in the home environments.

We also have outpatient services available. We have outpatient therapy here at Mount Washington, and we can also help provide some other suggestions for caregivers who might live at a distance to get outpatient therapy. And what that looks like is just follow up therapy once the child is home, from the same team so that we can continue to provide education to caregivers about the best positioning, about how head anomalies are hopefully resolving and getting better or what to do if they're not, what next steps to take.

Host: Okay, thank you so much for that. You know, still one of the things that I'm curious about is how you track your little infant patients just over time and just make sure that they're developing properly. I'm curious as to, if there are development clinics or developmental clinics offered at MWP age for infants and toddlers.

Dorothy: Yeah, that's a great question. We really do like to follow up with them after they go home if possible, because any infants who are born early or who might have these medical complexities early on are at risk for delays as they get older. One of the clinics that we have, actually is that Torticollis and Plagiocephaly Clinic and that is here at Mount Washington. And we recommend that for our little guys who have had head shape concerns along the way when they have been inpatient with us and particularly if those issues are not resolving. We also have another clinic that's called the MVP clinic, Making Valuable Progress. And a lot of our premature infants who are hospitalized here after birth are recommended for that clinic. It's a nice clinic to go ahead and look at the child medically, to look at their therapeutic needs, how their speech is developing, how their motor patterns are developing. We also have a psychologist on team, just to look at the child's overall needs as they get older and see if they need continued therapy or any other community supports.

Finally we have another developmental clinic, and that is the DEC clinic, Developmental Evaluation Clinic, which is for children with either known or already diagnosed delays or suspected delays. That team has a developmental pediatrician on staff who's able to really take a deep dive into what is going on with the child and support the child and family in getting their developmental on therapy needs met.

Host: Yeah, I have to say that's wonderful and reassuring to hear. There are going to be parents that are listening to this, that this conversation is really speaking to them. Maybe they've noticed some mild abnormalities in their infant's head and they want to get it addressed. So, who should they contact if they have concerns about their baby's head shape or just in general that our overall development.

Dorothy: I would say firstly, to speak to those parents, parents or caregivers are really the child's greatest advocate. So, if you have any concerns, even if they're mild or they're small, I think it's just a great to bring up to your pediatrician because as Nicole had mentioned earlier, really going ahead and getting concerns addressed early, gives us the best outcomes for therapy. So, really the best outcomes for the child. So, we would recommend always beginning with your pediatrician and having a nice open and frank conversation with them about any concerns. Hopefully the pediatrician would be able to further direct you if specialty services are needed. And then we also just wanted to mention that caregivers can go ahead and seek outpatient services or clinic care as well.

So, starting with a pediatrician is a great way to keep everybody on the same page, but to also feel free to advocate for your child and see okay, further physical therapy services or occupational therapy services as needed to make sure that your concerns are addressed regarding their posture or their head shape. All those issues.

Host: So, Nicole, just as we start to close here, one of the things that I was curious about is if parent starts to notice some of these head shape abnormalities, but chooses not to do something about it. I'm wondering about what are the risks of just leaving it be?

Nicole: Yes. If a parent chooses not to address the head shape, abnormalities during that most ideal window of treatment, there will be some natural progression and some natural improvement of the head shape. In most severe cases, I would say that there would still be some flattening that could occur, some facial asymmetry, that would maybe affect the child in their childhood years in terms of, let's say wearing a sports helmet, or having the proper fit of a sports helmet, also wearing glasses. If their ears are misaligned, that may be challenging. Sometimes the eye orbits can be misaligned, so that could affect their vision. There could be some effect on the jaw if not treated, if the jaw is asymmetrical or not aligned properly, there could be some problems with the TMJ joint, down the road. But overall parents can feel confident that it does not affect brain development in any way. So, it's really up to them to make the best decision for their child and their family as to whether or not they want to proceed with any helmet therapy.

Host: Okay. And final question and Dorothy, I guess I'll direct this one at you. Is there something that parents that are expecting can do to make sure that their baby's head shape comes out normal or healthy and just develops well. And I'm assuming, you know, just going to all of the normal appointments that we're supposed to is the best that we can do, but maybe Dorothy, if you can speak to that a little bit, that'd be great.

Dorothy: You're absolutely right. So, definitely, just going to your well-baby visits, is a great start. I would say the best thing to do is just to go ahead and give your child a lot of different experiences. So, it's great for children to be held and it's great for children to be held in different positions. So, lots of times, you know, we pick up the baby and we kind of hold them down in our arms so we can see them and they can see us. That's a great position. You can also hold them on the other side of your body. So, most of us have a way that we tend to just pick them up based on our handedness.

So, a great thing to do is to kind of think about that and think of and to hold them on the right side, I'm going to hold them on the left side of my arms. We love holding infants up on our chest, or at our shoulders. And that is a great way to give them a nice tucked in experience and all these different ways of holding the baby, gives their head, a lot of room to grow, right. So they're not, in one position for such prolonged time. Also, as Nicole had mentioned earlier, these days there's lots of great equipment available for kids, which is great, if used for small amounts of time, you know, the bouncy seat, obviously kids need to go in their car seat, all that stuff.

But trying to go ahead and get them out and hold them or play with them on the floor and just really move their position a lot is really what gives them the best chance to develop a nice symmetrical head shape as they grow.

Host: Yeah, that is great advice. And I think what I'm hearing is just moving the baby a lot, moving the position a lot, from the back, switching different sides to how you hold the baby. All of that is really important for the development of their head shape. So, Nicole and Dorothy, I really just want to thank you so much for your time today.

I learned so much and I truly appreciate it. To find more podcasts just like this one visit umms.org/podcasts. And thank you for listening to Live Greater, a health and wellness podcast brought to you by the University of Maryland Medical System. We look forward to you joining us again.