Roughly 1 baby out of every 5, under the age of 6 months in the US, now suffers from plagiocephaly, meaning an abnormal head shape. Treatment for this condition is time consuming, expensive and often fraught with confusion for parents because of having to sort through conflicting information.

The aim of this article is to present information on plagiocephaly so that parents have an easier time sorting through the process. It also offers tips on how to prevent plagiocephaly in section 7.

1. Plagiocephaly – What is it?
Plagiocephaly is an abnormal head shape in infants. Facial asymmetry, ear shifting and forehead sloping or bulging usually accompany it, although these features can be less noticeable. Plagiocephaly does not affect the brain.

The three main types of plagiocephaly are:
– Plagiocephaly
– Brachycephaly
– Brachycephaly with Plagiocephaly

2. Causes and Risk Factors
Plagiocephaly occurs when outside pressure is repeatedly applied to a particular area of the infant skull. Because infant skulls are soft and malleable, this pressure can alter their skull growth. This exterior pressure can also happen in utero, particularly with multiples or restricted space. Research finds that the average 2-month old baby now spends 15-16 hours a day on their back – allowing for a lot of external force to be placed on the same spot.

Risk factors:
– Premature babies have a much higher risk of developing plagiocephaly because their skulls are softer and thinner.
– NICU stays increase the likelihood because babies are held less and are often turned from side to side.
– Position in the womb can impact your baby’s head shape, especially with multiple births and restricted space.
– Convenience devices such as infant car seats, recliners and more mean babies are held less and not moved around as much. Twins can also spend more time in convenience devices due to the logistics of caring for two.
– Torticollis (tight neck muscles) can contribute to your baby preferring to turn to the right side or the left side. This condition can be treated with physical therapy and neck exercises.
– Babies sleeping on their backs to reduce the risk of SIDS (Sudden Infant Death Syndrome) has been the recommendation of the American Academy of Pediatrics since 1992. This important recommendation has decreased the incidence of SIDS by approximately 50%, but the rate of plagiocephaly has increased. Parents should adhere to the latest SIDS prevention guidelines while providing supervised tummy time and repositioning to prevent plagiocephaly.

3. How does your baby have plagiocephaly? (Diagnosing)
If parents notice their baby developing an unusual head shape they should bring it to the attention of their pediatrician. Pediatricians should also be assessing independently for this during routine visits. If there is reason for concern, pediatricians can refer parents to cranio-facial specialist for further assessment or suggest/prescribe a helmet specialists on their own. To have a helmet made, usually a doctor must write a prescription for it.

4. Does your baby need treatment?
This step can be confusing because when head abnormalities are mild to moderate, to treat a child or not, and how to treat a child, is largely a matter of opinion. Some pediatricians and specialists feel strongly about pursuing treatment, while others do not. Many waver somewhere in the middle.

Those who do not pursue treatment may feel:
– the baby will out grow the condition on their own.
– that the condition is not serious enough.
– that the condition is only aesthetic so treatment is not necessary.
– that the benefits of a helmet do not outweigh the negatives (cost, discomfort, effectiveness).
– that treatment is ineffective, unproven, or just as effective as repositioning a baby or a baby outgrowing it on their own.

During this step in the process parents should rely on what feels right to them. If an opinion is given which does not sit well with the parents, they should get additional opinions, research plagiocephaly on their own, visit a helmet provider independently for a consultation and/or ask to have their child’s head shape monitored. Ultimately the decision is up to the parents. A helpful question for parents to ask themselves during this process is, “if my baby’s head shape does not improve, will I feel comfortable with the type of treatment or lack of treatment I choose 10, 20 years from now?”

5. Treatment
If you have decided to pursue treatment, the two main ways to do it are repositioning and helmeting your baby.

– Repositioning involves keeping your baby off of the misshapen part of their skull and making sure you alternate which part of their skull they are putting pressure on. Repositioning is not effective for asymmetrical deformities, so generally only brachycephaly deformities will respond to this type of treatment.

– Helmeting your baby is the typical form of treatment. The aim of the helmet is to encourage or allow skull growth in depressed areas while controlling the growth in prominent areas. Helmets are most effective between four to eighteen months of age, and are worn for a few weeks to a few months, depending on severity and age of the baby.

Once parents have decided to move forward with getting a helmet for their baby, they must choose a helmet provider and the type of helmet, because not all helmets function the same although they may look similar. In fact, the most important aspect of helmet treatment providing a positive outcome is that the helmet is a good fit. The helmet should provide a snug, yet comfortable, hold on your baby’s more prominent areas while allowing space for growth in the depressed areas. Helmets that wiggle around do not provide the correct hold and straps should not be what keeps a helmet in place.

The three major differences in helmet providers are:

1. Experience and effectiveness. Helmet providers don’t generally provide statistics on how many babies they have treated or their success rate, but more established helmet providers do keep track of the number of clients and have staff with more training (physical therapists, occupational therapists, orthotists, RN’s). Also, some helmet makers only feel treatment is effective up until 12 months of age while others treat up to 18 months of age.
2. Technology used to create the helmet. Some providers use a cast of your baby’s head. Some use a single camera to capture your baby’s head shape and others use multiple wrap around cameras. In general the better the technology the better the fit of the helmet.
3. Type of helmet. Some helmets cover the entire head while others wrap around the forehead leaving the top of the head exposed. Again, the most critical part of treatment for a positive outcome is the fit of the helmet.

In addition to parent’s choosing which helmet maker they feel will provide the best and most affective treatment, parents should also consider:
– Location – Helmet use must be monitored, so weekly or bi-weekly trips to the provider are common.
– Insurance – Helmets are expensive. Health care plans may have preferred providers.

6. Latest Research
Many research studies have found that helmets do improve head shapes. However, the most recent study found virtually no difference in outcomes between baby’s that wore a helmet and those that did not at the age of 2.

Researchers assigned 42 babies, age 5 and 6 months with mild to moderate plagiocephaly, to wear helmets for approximately 6 months. They had another 42 babies wear no helmets. When the children were 2 years old researchers were not able to distinguish between those who wore a helmet and those that did not. Only about a quarter of the babies in the study made a full recovery by age 2.

Critics of the study say the study was inherently flawed due to treatment protocol, qualifications, and experience of clinicians treating the infants, exclusion of infants with torticollis and severe head deformities and because the design, function and types of helmets used in the treatment were not regulated so even ill fitting helmets were included in the study.

Parents should not use this latest study to influence their decision to helmet or not helmet their baby because of it’s flaws, most notably the lack of oversight on the fit of the helmets used.

7. Prevention
When plagiocephaly first begins it can be hard to spot. As the abnormality grows and your baby’s head grows, it can become more apparent. Ways to prevent plagiocephaly are:

– Tummy Time – this is an important activity. It helps strengthen neck and trunk muscles. It keeps babies off their backs. Not all infants enjoy tummy time. Start off with only a few minutes and build up to more time as your baby gets stronger. Be sure to supervise your baby during tummy time.
– Repositioning – While adhering to the SIDS guidelines, be sure to reposition your baby so they do not put pressure on the same part of their skull.

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