At birth, Rebecca Carley’s first-born son, James (pictured below at nine months), was a healthy baby with a round head covered with light brown hair.As time went by, she noticed that he always slept with his head to the left side and when awake, often tracked objects with his eyes rather than turning to look at them.After a couple of months, she was startled to see that he had developed a flat spot on his head.Although James’s pediatrician recommended physical therapy for his neck muscles, she expressed little concern about the flattening of his head. But she suggested a possible evaluation at Children’s Hospital Boston.

Flattening of the head can be asymmetric (plagiocephaly, derived from Greek for “oblique-shaped head”) or symmetric (brachycephaly or “short head”). Either type can be caused by positional forces (deformational) or fusion of a cranial suture (synostosis). Deformational plagiocephaly and brachycephaly stem from positioning in the uterus. Restricted head mobility in utero leads to neck tightness, which limits head rotation during the first few months of life. The rapidly growing infant head meets resistance from the flat resting surface (e.g., bed or car seat),and growth is re-directed.

The result is progressive cranial flattening. In plagiocephaly, this leads to asymmetric growth of the forehead, cheek, and ear on the same side as the flattening. In brachycephaly, the width of the head increases, making the head look “bigger.” Synostotic forms of plagiocephaly and brachycephaly are much less common and require surgery.

A Side Effect of “Back to Sleep”

The incidence of deformational plagiocephaly has increased dramatically since 1992 when the American Academy of Pediatrics recommended that infants be placed on their backs during sleep to reduce the risk of sudden infant death syndrome (SIDS).The “Back to Sleep” campaign has successfully prevented deaths but has led to many misshapen heads.

In the US, an estimated 15 percent of children, or approximately 1 in 7, now have deformational plagiocephaly. Babies who routinely sleep on their backs apply pressure to the rapidly growing cranium, which encloses the brain. (Although this affects the shape of the head, no reliable evidence suggests that brain development is affected.) Yet back-sleeping is only one contributing factor.“Position in the uterus plays a big part in the development of plagiocephaly,” says Gary Rogers, MD, the plastic surgeon at Children’s Hospital whom Rebecca Carley consulted.“Two-thirds of kids have flattening on the right side, because of the way they were positioned in utero.

“During the last trimester, space in the uterus is often limited, and the baby’s head may be lodged in a way that leads to neck muscle stiffness and contracture.” Tightening of one side of the neck, known as torticollis, occurs most commonly in babies who are: twins (or other multiple births), large in size (typically male), or firstborn (since the head may engage early in the pelvis). It’s also associated with oligohydramnios (too little amniotic fluid during pregnancy) and breech presentation. In addition, torticollis is particularly prevalent in premature babies.

Newborns with torticollis on one side usually lie with their head tilted to the tight side with the face rotated in the other direction. Until they develop head control (usually by three months of age), the infant is unable to shift head position and stretch the neck muscles to overcome the imbalance. Unfortunately, during these critical three months, the cranium is rapidly growing against a flat surface and the flattening worsens.

An Ounce of Prevention…

Does your newborn tend to look one way more than the other? The answer to this question can lead to early detection and prevention of deformational plagiocephaly. “For babies up to three months of age with a tendency to put their heads to one side, I advise treating them with a molding cup,” says Dr. Rogers, who designed the device, made exclusively at the NOPCO Brace Shop located at Children’s Hospital in Boston.The foam molding cup, which Dr. Rogers hopes to make available commercially, cradles and gently reshapes the head while the baby is lying down. More than 200 babies have already benefited from the use of the molding cup.

Based on his research, which will soon be published, Dr. Rogers rejects the notion that positioning can solve the problem.“Positioning is very ineffective,” he says.“The neck tightness strongly resists parental efforts to reposition the child’s head.”

Taking the Pressure Off

To help prevent flat spots from developing on your baby’s head, the American Academy of Pediatrics and the National Institute of Child Health and Human Development recommend these guidelines:

  • Provide “tummy time” when your baby is awake and being watched. (Placing babies on their stomachs also helps strengthen head and neck muscles.)
  • Change the direction your baby lies in the crib from one week to the next. (A baby has a natural tendency to face toward the entrance to the room. A weekly change of orientation may cause the baby to sleep with the head turned to one side, then the other.)
  • Avoid too much time in car seats, carriers, and bouncers, which put pressure on the back of the head.
  • Have upright “cuddle time.”

The Flat Pumpkin

Without developmental delays, babies can turn their necks and roll over at three or four months. Movement stops further flattening, but a misshapen back of the head cannot be outgrown.

“The flat spot won’t pop back out,” says Dr. Rogers.“It’s analogous to a pumpkin that starts out nice and round, but from growing against the ground, it becomes flat after several months. You can turn it on its end and let it grow for another few months, but you’ll still see the flat spot.”

James was nine months old when he first visited Dr. Rogers. He had grown big and healthy, but his flat spot persisted. Dr. Rogers diagnosed plagiocephaly by measuring his head diagonally in two directions (right rear to left front, and left rear to right front).These measurements, which should have been equal, had a striking difference of 18 millimeters. Dr. Rogers recommended that James wear a helmet to help redirect his head growth.

“We didn’t realize how significant the problem was,” says his mother, Rebecca.“Since he had a full head of hair from birth, it wasn’t easy to see.”

Helmets are nothing new, having been designed to treat this condition for 30 years.Yet in the past, plagiocephaly deformities usually affected the front of the head, because most babies were put to sleep on their stomachs.And unlike the cranium, the face, which grows very slowly until age 15 or 16, can selfcorrect over time.

Helmets, which are open on top for ventilation, redirect head growth using contact pressure (no pushing or squishing). Success depends on the age of the child (the younger, the better), severity of the problem, and compliance or willingness to wear the helmet. “If a helmet is worn for 24 hours a day, the parent will see some correction in four to six weeks,” says Dr. Rogers. “But if the child wears it 12 hours a day instead, it can take three times as long, since head growth slows with time.” Most health insurance, with the notable exception of Massachusetts state insurance, covers the cost of a helmet and growth-related adjustments.

Heading in the Right Direction

Based on a computerized head scan, Rusty Miller of NOPCO custom-made a helmet for James, which provides space for his head to grow in the desired direction. James wears the helmet, which is covered with pictures of cars, planes, and trucks (one of many patterns available), almost continuously with occasional breaks for feeding, bathing, and tummy time.

Once his mother realized how beneficial the helmet was, she got over her initial embarrassment.A fringe benefit of helmet wear, she notes, is worrying less about James hitting his head as he learns to stand and walk.

With the helmet, as well as an hour a week in physical and occupational therapy, James has made great progress. In less than a month, his asymmetry has been reduced from 18 to 8 millimeters.

“The helmet has made a huge difference,” says Rebecca.“The first week, he had a tough time [adjusting to it]. But not after that… Now it doesn’t faze him.”