What’s new in plagiocephaly? Clinical pearls from PEDIACAST and Dr. Mike
Gotta love babies’ heads!Those who know me as a pediatric physical therapist or know me through this blog are aware that I am passionate about babies, especially the development and shaping of their sweet little heads. I have written previously in-depth about the development of babies’ heads as they grow and parent questions about their baby’s head shape. About 50% of my current daily clinical practice involves evaluating and treating babies (how blessed am I?!), so I experience these questions and concerns daily. I am continually searching the medical evidence for information that designs my treatment and recommendations for these precious babies, and solid, evidence-based information to share with primary care providers, parents, and the therapists I mentor and teach. The topic keeps me busy and sharp, and I love it.
I have also previously written about my favorite podcasts that I access to help me retrieve and digest information. Nationwide Children’s Hospital, in central Ohio, is a leading pediatric clinical and research facility. They produce two wonderful podcasts by Dr. Mike: Pediacast, pediatric “news parents can use,” and Pediacast CME, geared more for physicians and clinical providers. Both cover a variety of topics with evidence-based, practical information. I like to listen as I travel back and forth between my offices, and its a convenient opportunity to hear what’s new in pediatric research literature.
Recently, I listened to an episode from February 2017 awkwardly titled, “Abnormal Baby Heads.”
Dr. Mike Patrick, the host of Pediacast, is a board-certified pediatrician and Fellow of the American Academy of Pediatrics, an Assistant Professor of Clinical Pediatrics at The Ohio State University College of Medicine and an Attending Physician with the Section of Emergency Medicine at Nationwide Children’s Hospital. I appreciate his combining research with clinical practice and family perspectives. On this podcast, Dr. Mike interviewed Dr. Gregory Pearson, a plastic and reconstructive surgeon at Nationwide Children’s Hospital, an assistant professor of Plastic Surgery at Ohio State University, College of Medicine and the director of the Center for Complex Craniofacial Disorders, a multi-specialty clinic that cares for children with skull abnormalities. Both physicians are well-experienced on this topic and articulated the information clearly.
Here are 8 clinical pearls or “take-aways” I picked out from this episode, either good reminders or new thoughts from the current research on plagiocephaly:
- Why we monitor baby’s heads closely in the first year: “there’s tremendous brain growth in the first year of life. As a matter of fact, it triples in size and quadruples by the second year.” The brain growth expands the moveable skull or cranial bones. Asymmetry or atypical proportions during this period can either improve or cause further difficulties. Watch carefully!
- The linking and expanding system: sutures, the fibrous bands of tissue that connect the bones of the skull, are “just a physiological point where there is rapid deposition of bone and resorption of bone. …They’re just where the junctions of the (cranial) bones have come together.” Surprisingly, research show that sutures do not fully close until about 20 years of age, except for the metopic suture which studies show closes within the first year. But, as noted, the most critical period of skull growth occurs during the first year.
- Plagiocephaly: “plagiocephaly just means you have a slanted, flat head or an abnormal head shape. But it’s not more descriptive than that.” There are different types of plagiocephaly….
- Almost 50% of Babies: “It’s (Back-to-Sleep Campaign) been great for Sudden Infant Death Syndrome but ever since that, there’s been a large increase (in plagiocephaly). So much that some literature says that up about 46% of kids at six months of age, have some components of positional plagiocephaly.”
- Reassurance: “Positional plagiocephaly is just (a) benign issue. It doesn’t have any functional considerations. And you’d be amazed that the number of parents once they hear that, they’re extremely relieved, because they’re concerned about pressure on the child’s brain. Or they’re concerned about development. But positional plagiocephaly is benign, non-functional issue.”
- Natural course?: Will plagiocephaly round itself back out or does the flat spot stay? “It kind of depends upon the severity of the flat spot, some other comorbidities or other things going on, if the child has some what we call hypotonia, which means they’re not quite lifting their head up as much. But a lot of times, especially in the more milder cases, it does get better, especially as you’re sitting them up and holding them up and doing the ‘boppy’ or ‘bamba’ whatever it’s called nowadays kind of thing. And as they start to roll over in the crib, again you should always put your child back to sleep with nothing in the crib before a year of age. But some kids will start to roll from back to belly to sleep comfortably. So it does tend to round out.” But…..
- Who needs treatment? How do you decide whether to do that (helmets or cranial remolding orthoses (CRO) or not? “Some of it is based upon the severity. Because as a child has more severe positional plagiocephaly, they can actually have some facial asymmetry. So for children who have some facial asymmetry, it can be very helpful, who have a pretty severe flat spot. Maybe they’ve tried conservative measures that we talked about. Helmets can be helpful. And sometimes, it’s patient and parent preference and how nervous they are about how round their child’s head shape needs to be.”
- What point do you watch (plagiocephaly) and what point do you say we need to do something? Are there some red flags that folks should be looking for? “I think if you have some concerns early on, the primary care doctor I’m sure is going to see the child pretty frequently and measure that and look and clinically evaluate. Three months (of age) is a good time for us because it still gives us a lot of opportunities. …The challenge we get into is when it’s been followed for eight or nine months and then that does limit some of our options.”
For those who are seeking more information, Dr. Mike and Dr. Pearson also spoke about craniosynostosis, a more rare cranial deformity that needs to be considered in the differential diagnosis of plagiocephaly since it typically requires surgical intervention. You can hear the full podcast here. Check out their other helpful episodes as well.
So, nuzzle those sweet baby heads, watch closely for asymmetries or flattening, and mention any concerns to your primary care provider early and repetitively if needed. Pediatric physical therapists are skilled and experienced at taking cranial measures, recommending positioning options, and suggesting specific activities. In general, to prevent or minimize the risk of plagiocephaly, introduce tummy time and floor mobility early and repeat frequently (5-6 short, successful times a day). If you notice concerns, here are some additional suggestions for tested strategies parents and caregivers can use. Remember, safe back-to-sleep but supervised tummy-to-play.
Thank you to Dr. Mike and Pediacast for always researching, digesting, and explaining important topics for parents and pediatric professionals using evidence-based information and recommendations. I look forward to future episodes on-the-go!
~ Karen PT