Heading off a problem

GHS’ interdisciplinary team offers expertise in a range of treatment protocols to correct an infant’s head shape.

Roman Davis sports his cranial remolding helmet.

Photo provided by Megan Davis.

When Charlie Brown is called the “roundheaded kid,” it doesn’t sound like a compliment. But a rounded head, especially in babies, is a good thing. What parents and providers don’t want to see are signs of plagiocephaly. This common disorder develops when an infant’s soft skull becomes flattened in one area, due to repeated pressure on one part of the head.

Sometimes brought on by a baby’s preference for sleeping or sitting with the head turned consistently in the same direction, plagiocephaly is a treatable condition that requires early intervention. Treatment can include performing special exercises, varying sleep and play position, wearing custommade cranial remolding helmets and, in some cases, having surgery.

Parents and pediatricians: the first line of defense

Plagiocephaly can become apparent when a baby is between 2 and 4 months old. As soon as a concern arises, parents should contact their pediatrician. Megan Davis, a Greenville mom of three, observed in late 2017 that her youngest son’s head had an atypical shape.

“About a month after Roman was born, I noticed his head didn’t look like his brothers’, but I couldn’t put my finger on why,” Davis recalled.

Her next step—calling a physician—was the right one, according to Joe Maurer, MD. Dr. Maurer is a pediatrician with The Children’s Clinic, a practice of Greenville Health System.

“I recommend parents ask me their questions right away, as opposed to worrying or going online,” Dr. Maurer said. “I’d rather be the source of answers than have them get information that may not be accurate or applicable.”

A pediatrician can offer more than just reassurance to families, advised Andrew Burgess, MD, of GHS Pediatrics & Internal Medicine–Wade Hampton.

“We often send parents home with exercises to incorporate into their baby’s routine, as well as guidelines for tummy time and sleep positioning,” Dr. Burgess noted. “Outcomes suggest that early physical therapy is beneficial, and a referral to PT may be our next step in cases where it’s warranted.”

Elizabeth Hitchcock, a physical therapist with Kidnetics®, the pediatric therapies arm of Children’s Hospital of Greenville Health System, reiterated that early intervention makes all the difference: “Before 3 months of age, newborns’ heads are so malleable that plagiocephaly is more easily treated with conservative measures.”

On the rise

The incidence of plagiocephaly has skyrocketed in recent decades, according to Hitchcock.

“The Back to Sleep program started 25 years ago to reduce sudden infant death syndrome (SIDS), and it has been a wonderful success,” she remarked. “SIDS deaths have been cut in half simply by placing babies on their backs to sleep. As a result, though, the incidence of positional plagiocephaly has increased markedly.”

Hitchcock pointed out that simple solutions exist.

“A physical therapist’s first intervention to all parents, whether they are concerned about baby’s head shape or not, is to advise as much tummy time as their baby will tolerate,” she said. “Not only will it strengthen infants’ back, neck and shoulder muscles, but it also takes pressure off the back of their heads. Incorporating snippets of tummy time throughout the day will allow the baby’s head to reshape beautifully.”

Benefits of physical therapy

When positioning alone does not allow an infant’s skull to properly reshape, families are referred to physical therapy. The same is true for babies with torticollis, a tightening of the neck muscle, which makes them look to one side and interferes with head shape development.

Mary Jones, Kidnetics’ physical therapy supervisor, stressed that cases don’t need to be severe to benefit from therapy.

“We would rather see parents and tell them that they don’t need us than find out later that we should have intervened months beforehand,” Jones emphasized. “Particularly if plagiocephaly is due to a muscle tightness in the neck or a baby’s habit of looking in one direction, allowing it to become a longer-term habit can make it harder to resolve. If we see an infant early, we can work through issues faster.”

When caregivers are referred to Kidnetics, they can expect a therapist to observe their infant’s range of motion, take measurements of the head and make decisions based on those findings. Kidnetics sometimes sends patients to GHS’ Center for Prosthetics & Orthotics after taking initial measurements. Many families see positive changes simply from positioning their babies upright in baby carriers, adjusting their sleep positions, providing more tummy time and incorporating recommended exercises.

Hitchcock, who spearheaded Kidnetics’ torticollis physical therapy program, pointed out that head shape and neck tightness have more than just aesthetic consequences: “Over time, babies can develop facial asymmetries, which may lead to feeding issues, using one side of the body more than the other, and even vision difficulties. It’s about a lot more than a round-shaped head; catching these cases early can prevent long-term issues.”

She continued, “We demonstrate massage techniques, how to improve neck range of motion, how to perform exercises that will strengthen their babies. Caregivers walk away with tools that benefit their babies long after they leave Kidnetics.”

Cranial remolding

If physical therapy and repositioning do not improve a child’s head shape or when a pediatrician and PT team determine additional reshaping efforts are needed, the next step may be a referral to the Center for Prosthetics & Orthotics for cranial remolding.

“These specialists create molding helmets to help round out a baby’s head shape,” remarked Katie Lichty, NP, with GHS’ Division of Pediatric Neurosurgery. Patients usually respond very well to custom-made helmets.”

Jeanne-Marie Beaupre, CPO, a prosthetist/orthotist with the Center for Prosthetics & Orthotics, shaves down the foam inside a cranial remolding helmet

Beaupre examines a young patient during a follow-up appointment.

These helmets function alongside a baby’s natural growth to reshape the skull in a customized orthotic lined with foam. Regular reviews and adjustments ensure that the patient is responding to treatment as expected.

But not every baby referred to the center needs a helmet. “We see about 300 children a year for a plagiocephaly evaluation and may recommend treatment on only half of them,” said Todd O’Hare, a certified prosthetist/orthotist and manager of the center.

“The process is gentle, not painful,” he added. “Patients have weekly follow-ups, often for 10-18 weeks, and then that chapter of a baby’s life is closed. It’s a new and scary thing for parents, but their babies are in experienced hands here. Our level of specialized technology for evaluation and treatment sets us apart. We’ve focused on treating infants with plagiocephaly for over 15 years.”

When neurosurgery is needed

Occasionally, babies with plagiocephaly or similar concerns are referred to Christopher Troup, MD, at Pediatric Neurosurgery (part of GHS Children’s Hospital) to rule out craniosynostosis, a condition in which a baby’s skull bones fuse together and create an atypical head shape.

“An infant’s skull is actively molding, so it is not one solid thing,” explained Dr. Burgess. “It has different suture lines that separate it until it’s fully fused. If a suture closes prematurely, it limits the skull’s ability to grow as the brain does, and that’s a cause for concern.”

Babies presenting with craniosynostosis get an instant referral to Dr. Troup and his team.

“We are fortunate to have a world-class pediatric neurosurgeon here in Greenville,” Dr. Maurer observed. “Professionally, he is unmatched; personally, he is entirely committed to the care of his patients and families.”

Roman Davis immediately after his surgery for sagittal craniosynostosis at age 3 months

Lichty said that Pediatric Neurosurgery performs several suture surgeries a month for patients with craniosynostosis, usually seeing 20-25 plagiocephaly cases a week.

“A lot of times these babies are referred for abnormally shaped heads,” she said. “When we assess and possibly scan them, we can determine their exact diagnosis and how to treat it.”

For Roman Davis, a referral to Pediatric Neurosurgery and a CT scan confirmed that the 3-month-old had sagittal craniosynostosis, which required surgery. His mom realized the timing was perfect.

“The brain has nowhere to go when a baby’s skull sutures are fused,” Davis pointed out. “We are thankful to have corrected this issue when we did.”

Lichty agreed, noting that the window of time for action ideally is less than 5 months old, but there are other surgical interventions available if the child is older.

Sending a baby into surgery isn’t something Davis anticipated, but said, “Dr. Troup put us at ease. Skull surgery seems overwhelming, but he made us feel like it would be like a simple trip to the dentist. The process could not have gone better.”

She added, “Within 48 hours of surgery, Roman looked like a completely different baby, like he was meant to look all along.”

Family photo of Roman Davis and his parents and older brothers.

Photos provided by Megan Davis.

Continuity of care

O’Hare appreciates that within GHS, his patients’ families have access to many specialists under one umbrella, saying, “We communicate, collaborate and bring every necessary piece to the puzzle. It’s the ideal set-up for patients with plagiocephaly, craniosynostosis and other diagnoses.”

Jones pointed out the convenience of storing all patients’ health information on a central electronic medical record: “We have our notes on a common electronic program, share every session’s details with our patient’s pediatrician and collaborate with the orthotics team, too. We can see each round of measurements as they’re updated, so the whole team stays informed.”

For every member of the GHS team, the vision is long-term, according to Hitchcock.

“We want to take away the mystery and emphasize that head shape concerns are transient,” she remarked. “This time next year, the family should not be worrying about these issues.”

Davis’ concerns for Roman’s head shape have dissipated. “Today, he’s busy crawling around with a perfectly round little head,” she said. “It’s not a condition that will affect him at all long term. He will run, jump, play and do everything his brothers do.”