Deformational plagiocephaly, also known as positional or occipital plagiocephaly, is a condition in which an infant's skull becomes asymmetrical (misshapen) due to repeated pressure to the same area of the head. Plagiocephaly originates from the Greek words "plagio", meaning oblique, and "cephale", meaning head. Because an infant's skull is soft and pliable in order to pass through the birth canal, a baby is especially susceptible to deformational plagiocephaly in the first several weeks after birth. When an infant's head stays in one position for extended periods of time, external pressure causes the skull to develop an abnormally flattened shape. This often results from a repetitive sleeping position. It is possible for a baby to be born with deformational plagiocephaly due to a tight intrauterine environment such as in situations of multiple births, breech position, or a small maternal pelvis.
Factors which can cause misshapen head in babies include:
- Congenital muscular torticollis: A congenital condition involving the tightening of the neck muscles causing the head to turn or tilt in one direction.
- Prematurity: Because the majority of cranial bones strengthen in the last ten weeks of pregnancy, premature infants have a higher risk of deformational plagiocephaly, especially if they spend extensive time in a neonatal intensive care unit (NICU) with their heads in a fixed position.
- Back (supine) sleeping: Cases of deformational plagiocephaly have dramatically increased since 1992, when the American Academy of Pediatrics (AAP) recommended that infants sleep on their backs (supine) in order to reduce the risk of sudden infant death syndrome (SIDS). While it is still encouraged that babies sleep on their backs until they can roll over, alternating head position is recommended.
Diagnosis for Deformational Plagiocephaly – Misshapen Head in Babies
Diagnosis for deformational plagiocephaly can usually be made through a basic examination of your child's head. A child with deformational plagiocephaly is often born with a round head and develops a deformed head shape within a few weeks or months. If there is any doubt of the diagnosis, your doctor may recommend skull x-rays or a CT scan to rule out craniosynostosis.
Deformational Plagiocephaly vs. Craniosynostosis
Craniosynostosis is a rare, but serious, condition in which the sutures in the skull fuse prematurely. While both craniosynostosis and deformational plagiocephaly involve an asymmetrical head shape, craniosynostosis results from internal events that can impair brain growth. Deformational plagiocephaly is caused by external forces that typically do not affect a child's mental development or brain growth. Deformational plagiocephaly improves with repositioning therapy while craniosynostosis usually worsens over time and requires surgery to correct. A CT scan and/or an MRI are generally needed to confirm a diagnosis of craniosynostosis.
Treatment for Deformational Plagiocephaly – Misshapen Head in Babies
If your child is diagnosed with deformational plagiocephaly, treatment will be determined based upon the severity of the condition. The first treatment usually involves head repositioning, changing your baby's laying position to ensure that he does not consistently lay on the flattened side. Giving your child tummy time while awake and supervised is also recommended. Deformities that are mild to moderate can usually be corrected with repositioning measures, especially if utilized by 3-4 months of age. Recommended methods of repositioning include:
- Alternating your child's direction in crib: One night place your child's head toward the bottom of the crib, the next night, toward the top.
- Alternating your child's head position during sleep: One night let the right side of your child's head touch the mattress, the next night, the left side.
- Moving your child's crib: Your child may be looking at a specific item in the room causing him to keep his head in the same position.
- Do not place your child on his back while awake.
The AAP does not recommend the use of devices that could restrict an infant's head movement. Be sure to consult your doctor before using any type of wedge pillow to assist with repositioning.
Congenital Muscular Torticollis (CMT) Treatment
Some cases of deformational plagiocephaly are caused by muscular torticollis, a condition involving tightened neck muscles which decreases the neck's range of motion. Torticollis often causes an infant to hold his head in the same position against a car seat or mattress. Congenital muscular torticollis is a factor in approximately 10-15% of children with deformational plagiocephaly. Along with repositioning measures, physical therapy is recommended to stretch the neck muscles in order to increase range of motion. Home exercises which consist of stretching the neck to the side opposite the tilt will help elongate and strengthen the neck muscles.
Most cases of deformational plagiocephaly respond well to repositioning or, in cases of torticollis, to therapy. For children with moderate to severe deformational plagiocephaly or for those who do not respond to repositioning or therapy, a custom molding helmet or headband is usually prescribed.
Helmet Molding Therapy: Cranial Orthotic Treatment for Deformational Plagiocephaly
Helmet molding therapy is less invasive intervention for deformational plagiocephaly is cranial orthotic treatment to remold the baby’s head. Cranial remolding helmets or bands are made of a hard outer shell and have an inner foam lining. These custom-made cranial orthotic devices are designed to discourage additional skull growth by providing contact over the prominent areas of the skull. The helmet is modified to give extra space in the areas where the head is flattened. The gentle, but constant, pressure on the baby's head redirects the growth of the skull.
Helmet molding therapy using a cranial orthotic device is not treatment for infants with craniosynostosis or hydrocephalus.
Originated in 1979, the molding helmet's design was based on the concept of surrounding the asymmetrical head with a normal, symmetrical mold in order to reshape the skull. In 1998, Dynamic Orthotic CranioplastySM (DOC Band®) was developed as an alternative technique. The DOC Band® utilized a more proactive approach and was the first device to be approved by the Food and Drug Administration (FDA) for treating plagiocephaly. The DOC Band® is customized for the specific type of plagiocephaly the baby has, is lightweight (about 6 ounces), and painless for the baby. Today, a wide variety of helmets and bands are available which are based on the concepts of the original molding helmet, as well as the DOC Band®. Your doctor will advise you as to which product will be most beneficial to your child's successful treatment. Molding helmets work best when skull growth is at its fastest (between 4-6 months of age).
Creating the Remolding Helmet for Misshapen Head in Babies
A specially trained orthotist will design the remodeling helmet specifically for your child. The first appointment may include:
- Taking photographs of the skull
- Measuring the skull with calipers (compass-like instrument to measure the external head dimensions)
- Performing a scan to assess skull shape
These measurements and pictures will assist the orthotist in creating a duplicate of your child's head using a 3-D scan or plaster impression
The customized helmet will need to be worn 23 hours per day, being removed only for bathing or cleaning. Adjustments will need to be made every one to two weeks since your child's head grows quickly during this time. The foam lining and the outside plastic helmet will require periodic adjusting, and in some cases, a second helmet may be needed. Helmet molding therapy typically lasts between 3-6 months. If an infant is older than six months, treatment may take longer. Because the skull bones become more rigid after age one, correction can require surgery in older babies. Your doctor may also recommend surgery for severe skull deformation.
Molding helmet therapy should never be used without close supervision from a licensed physician with craniofacial experience. Do not purchase or use any helmet or headband device unless prescribed by your craniofacial doctor.
Reducing the Risk of Deformational Plagiocephaly
Simple measures can be taken that will greatly reduce your child's risk of developing deformational plagiocephaly. These include:
- Providing your child with plenty of tummy time: Helps build and strengthen neck, arm, and shoulder muscles.
- Avoiding excessive time in carriers, bouncers, or car seats while your child is awake.
- Changing the direction your baby sleeps in the crib every few days.
- Frequently holding your baby upright over your shoulder during the day.
- Changing your baby's head position from side to side during feeding and while holding.
- Occasionally changing crib location so your baby has to look in a different direction in order to see the window or door.
If you would like more information about helmet molding therapy for misshapen heads in babies, please contact the Craniofacial Team of Texas.