My infant son has a flat head. We'd heard the admonishments to change his head position when we put him down to sleep, but the moment he gets tired, crreeek: He cranks his head around to look to his right, tilting it back to the left.
At our two-month check-up the pediatrician said to keep an eye on it. At four months, she took one look at the flat plane stretching from his right ear to the back of his head and wrote a referral to a physical therapist. And I immediately found out that we're not alone. The scheduler at Children's Hospital in Minneapolis said, "Yep, that's the number one most common reason anyone calls us."
Nobody knows exactly how many babies have positional plagiocephaly (a flattened head caused by continuous pressure on one side or the other, rather than by abnormal fusing of the bones). But everybody agrees that the numbers have gone up dramatically (some clinics reported a six-fold increase) since 1992, when the American Academy of Pediatrics recommended babies be put to sleep on their backs to reduce the risk of sudden infant death syndrome. Some studies have shown that more than 15 percent of all infants have some degree of flattening of their skulls.
Kathy Grinde, a physical therapist at Children's, says, "When babies are on their backs, they're far less likely to change their head position. That's why we recommend babies get plenty of time on their tummies when they're awake. So we say, 'Back to sleep and tummy to play.'"
There are actually two things going on here: torticollis, which is congenital shortening or damage in an infant's neck muscle, causing the head to tilt to one side; and plagiocephaly, the flattening of the head that might be associated with it.
"The sooner you identify this and the faster you follow-up on it, the better off your baby will be," says Grinde. "We're encouraging pediatricians to make referrals as soon as possible. A lot of physicians wait for the four-month checkup, when intervention can be more challenging."
The first course of intervention for both conditions is physical therapy. In weekly or biweekly sessions, parents learn exercises that encourage babies to stretch their neck muscles, using the full range of motion on both sides. Babies also need to learn to "play in the middle": using both sides of their bodies and both hands equally. If torticollis is left untreated, babies may continue to favor one side over the other, which can lead to problems in crawling and other physical milestones.
Babies' heads are still growing very rapidly in the first seven or eight months of life and usually round out with repositioning. But if physical therapy is not enough, some babies are referred to craniofacial specialists who may fit them with a cranial cap-a helmet that keeps pressure off the flattened side of the head, allowing it room to round out.
It's easy for an anxious parent to imagine that a flattened skull might affect brain development, but Cheryl Shell, a pediatric nurse practitioner at Gillette Children's Hospital in St. Paul, says this isn't the case. "As far as we know at this time, there is no functional deficit caused by plagiocephaly," she says, adding that the research on the subject is still sparse.
There are, however, certain facial distortions associated with plagiocephaly, she says: The ear on the flat side can be shifted forward and features on that side are more prominent. "The cranial cap is a noninvasive way to prevent that," she says. "We have parents who come in with much older children, kids who can't find bike helmets or hockey helmets that fit. But after a year [of age] there's really nothing you can do."
After a few weeks of physical therapy and a newfound interest in belly-crawling, our son's head has already rounded out dramatically. Grinde stresses that tummy time, from birth, is an important preventive measure. "Hold your baby on your chest if she doesn't like being on the floor," she says. "We need parents to be aware that a child's head is very moldable."
