Barbara S. Greenstreet, M.A
As an Early Interventionist, I am often approached by parents with questions and concerns about their baby's development. Recently, Diane stopped in to my office, with her three month old baby in her arms.
"Just look at the shape of her head!" she exclaimed with concern. "It's totally FLAT on the back! Do you think she's OK?"
Diane is not alone in her worry. Over the last several years, pediatricians have seen an increase in the number of infants with this condition, which may be called positional or occipital plagiocephaly, or cranial asymmetry. It simply means that the head is shaped unevenly, usually with a flattened area on the back or one side of the skull. Recently, most cases of the irregularity are traceable to a safe and healthy reason: "Back To Sleep."
Since 1992, when the American Academy of Pediatrics first publicized its recommendation that infants be put to sleep on their backs - supine, rather than prone - parents and their children's doctors have reported an increase of babies with "funny shaped heads," as parents often express it.
The Back To Sleep habit has significantly reduced incidents of Sudden Infant Death Syndrome (SIDS), by 40% according to some reports, and this is great news. But one side effect is that infants tend to have the same part of their head against the flat mattress every night, as well as during naps, and they often develop a flatter area there. (Bald spots are also common, but resolve as new hair grows in.)
In fact, this cranial asymmetry can occur for several different reasons, including position in the womb or short, tight or sore neck muscles; in addition to the back-sleeping.
Pediatrician Dr. Stephen Tarzynski, Assistant Chief of Pediatrics at Kaiser-Permanente Health Center's West Los Angeles facility, comments, "A baby's head is like a water balloon. We're finding a lot of babies who are getting flat heads in back."
Just how serious is this problem? Many parents are concerned that the flattening may affect brain development, and either cause or be a sign of a disability. Dr. Nancy Shinno, co-director of the Kaiser Craniofacial/Cleft Palate Team (Kaiser-Permanente, Southern California) writes, "This asymmetry will not cause any brain damage. The major problem that results from such a head shape is that one ear is usually farther in front than the other ear, and this may make it difficult for your child to wear glasses later in life."
When should a parent be concerned? How much flattening is still "within normal" and at what point should you consult your baby's doctor about this?
Of course, you should always contact your child's doctor right away about any concern, including the shape of your baby's head. The doctor should take head measurements at regular well-baby check-ups to ensure normal head growth.
Dr. Roger Knapp, a pediatrician in private practice in Southlake, Texas, adds that if he has not seen the infant turn its head to each side, "I ask the parents at the two week checkup, 'Can the baby turn it's head both ways?' I also notice if the baby cries when I turn the head to the side."
In fact, no one has a perfectly round or oval, symmetrical head. As the baby's hair fills in, and the body grows to become more proportionate with head-size, the irregular shape becomes less noticeable. Also, the shape normalizes more once the baby has matured enough to move its head freely, lift its head easily from the surface, and to turn over or roll independently. Typically, by about eighteen months of age the head has attained more of the expected roundness or symmetry.
Still, there are several techniques recommended to help your baby's head develop more evenly, and to reduce the flatness if it has already appeared.
Dr. Tarzynski of Kaiser-Permanente explains, "To prevent flattening we recommend turning the baby on his/her belly for about an hour a day (it can be three times for 20 minutes, four times for 15 minutes, etc.) while being watched closely by the parent. This seems to mitigate the asymmetry from that cause."
Many developmental experts agree and some advisie even more time spent in the prone (tummy-down) position each day. Kathy Ludlow, OTR/L, a pediatric motor therapist in North Bend, Washington, urges parents to give their babies plenty of "tummy-time" during waking hours each day. "This is important not only for head shape, but also for general development of body strength, and fine and gross motor skills."
The American Academy of Pediatrics has noted that attainment of infant gross motor milestones (sitting independently, crawling) does appear to occur slightly later in infants who sleep on their backs as opposed to side or front-sleeping, although the lag resolves by eighteen months. More parents report later crawling, and in some cases no crawling at all, in their back-sleeping babies.
Ludlow emphasizes, "A generous portion of time spent playing on the floor will ensure that babies use their hands, arms, and full-body muscles to move and explore." Carseats, swings, 'exercise saucers' and infant carriers have their usefulness, but," says Ludlow, "Every baby needs daily time without the support of these types of equipment to develop their muscles, as well as to allow for even head development."
Breast-feeding naturally encourages parents to hold the baby on each side, which helps with even head growth. If you are bottle-feeding, be sure to do the same, either at each feeding or alternating feedings, change which arm you cradle the baby with to vary the direction the baby faces.
Drs. Nancy Shinno and Andrew Wexler of the Craniofacial Team at Southern California Kaiser-Permanente offer these guidelines to parents, to reduce the uneven pressure on the baby's head:
• Alternate the placement of mobiles, toys and other objects of interest near the baby's crib, so that he or she will turn in different directions to see them.
• Switch your baby's position in the crib (which end of the mattress the head is toward), so that he will have to turn the other way to look at you (especially if you sleep in the same room), the door, or the room in general.
• Use variations in car seats and strollers as well: hang toys or objects of interest on different sides at different times. If an older sibling frequently rides in the car with the baby, alternate which side of the car seat he or she sits on, as the baby is likely to turn in that direction.
• Let baby be on his stomach as much as possible when awake (with your close observation).
• When your baby has developed good head control, the occasional use of a 'jumper,' swing, or saucer will give your baby variety without added pressure to the head.
Occasionally, if these measures are not enough to prevent or resolve any flattening, a special helmet may be prescribed to mold the skull into a more rounded shape. The baby generally must wear the helmet 23 hours per day, seven days a week, taking it off primarily for bathing. Usually a few weeks to a few months with the helmet therapy will correct the problem.
Remember that no one is perfectly symmetrical in head-shape or in other features of the body. "I wear two different shoe sizes!" comments Dr. Knapp, of Texas. Often a baby's head shape is as much the result of inherited traits as it is positioning.
Diane, who was reassured by her pediatrician that her baby's head was rounding out nicely on its own, realized that several people on her husband's side of the family had similarly squarish heads, when she looked closely. "At least she's a girl!" she laughs, brushing her baby's wispy infant hair. "We'll just let her have longer hair, or even curl it a bit, to camouflage the flat spot, if she still has one!"
Barbara S. Greenstreet, M.A., is a freelance writer and Early Intervention Specialist with over 20 years' experience teaching infants, toddlers and preschoolers with developmental delays and disabilities.and counseling families of children with special needs. She lives with her husband and three teenagers in western Washington State, and writes frequently on parenting and child development topics."
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