To Helmet Or Not To Helmet? That Is The Question.

Posted on August 6, 2020August 18, 2020

Posted by Dr. Monica Wonnacott | August 6, 2020

When the American Academy of Pediatrics recommended that babies sleep on their back to prevent SIDS (Sudden Infant Death Syndrome), there was a sharp rise in the problem of flat heads in babies. More babies were sleeping on their backs and their heads were getting flat as a result. Since sleeping babies on their backs dramatically decreased the number of cases of SIDS, having babies just sleep on their bellies again was not a viable option. So what came of all those flat heads? The baby helmet industry was born.

Everybody has seen a baby wearing one of those baby helmets or DocuBands (a type of partial helmet). The idea is to put pressure on the parts of the head that are sticking out and leave room for the flat parts to fill in a more rounded shape. The goal is that you gradually reshape the head over time. So why not just use a helmet?

Problems with helmets:

The helmet interferes with natural cuddling and interactions with your baby.
The baby has to wear the helmet 23 hours a day, 7 days a week, for multiple months.
The helmet is heavy and uncomfortable.
The helmet (by nature of applying pressure to the parts of the head that stick out) can rub or irritate the skin and/or leave sores.
The helmet causes the infant’s head to be hot and sweaty.
The helmet starts to have a bad odor.
The helmet attracts unwanted attention (it simply feels bad having people stare or make ignorant comments about your baby’s appearance).
The helmet is time consuming, requiring multiple appointments for frequent adjustments.
The helmet is expensive, averaging $2300.00 and is often not covered by insurance.

How likely is an adverse effect from a helmet?

Your infant is essentially guaranteed to experience at least one adverse effect from using a helmet. A 2015 study published in the NIH, confirms this. It showed that ALL parents reported at least one adverse effect (not including lost time or economics in that list) from the children that received the helmet intervention group (compared to no a no helmet group).

Should my baby use a helmet?

Whether or not you should invest the time, money, and effort to pursue a helmet can be tricky. Pediatricians seem to have different thresholds for when they refer patients for helmets. Most agree that very severe cases should be referred for a helmet.

How do I know If my baby’s flat head is severe?

Baby’s with severe cases have very misshaped heads. The average person doesn’t have to look from any certain angle to determine that the baby’s head is flat. It is particularly concerning when the opposing forces from the flat spot cause the face to become uneven (e.g., the eyes or ears are uneven, the forehead sticks out on one side). When a child’s face is markedly uneven, it becomes visually distracting and is generally a good indicator that it may be time for a helmet or band.

Do I have to use a helmet if my baby’s head is just mild or moderately flat?

No. While you may still choose to use a helmet/band, the scientific evidence on it’s effectiveness for mild to moderate cases is mixed. According to the AAP,

“There is currently no evidence that molding helmets work any better than positioning for infants with mild or moderate skull deformity.”

What can I do instead of a helmet?

The most important thing to do is to relieve the pressure on the flat spot of the head. This is done primarily by repositioning the head during sleep (turn the head away from the flat spot). The hard part is getting the baby to keep the head in the new position; many babies will automatically reposition the head to the flat side as it is the comfortable position. The AAP discourages the use of sleep positioners and pillows as they are a suffocation risk. So what is a parent to do? The MoWo solves this dilemma. Since the positioner is attached to the infant’s back, it is impossible to suffocate on it. It keeps the infant positioned to allow the head to naturally and comfortably rotate to the correct side.

Additional measures beyond repositioning include: neck stretches (the muscles of the neck can get tight causing the head to stay positioned to the flat side), encouraging lots of tummy time and sitting up, and avoiding excess time in car seats (or other items that cause the head to rest against something hard).

Congenital Torticollis: The Tilted Head And Neck

Posted on February 8, 2017August 18, 2020

Posted by Dr. Monica Wonnacott | February 8, 2017

Have you ever seen an infant that seems to favor moving his/her head to one side or direction? It may be that the neck twists or that the head tilts, but there is definitely a preference to one side over the other. This is a phenomenon called torticollis or wryneck. Torticollis in Latin means “twisted neck.”

Why does it happen?

When you grow a whole human in a tiny sac, things are bound to get cramped. If the infant is positioned in the womb such that the head/neck is bent, then the child is likely to prefer that side when he/she is out of the womb. Difficult childbirths (like those that require forceps or vacuums) can also put strain or stress on neck muscles and cause torticollis. While congenital torticollis is usually noticeable at the time of birth, it can take a couple of months to develop.

Although rare, it is also worth mentioning that torticollis can happen as a result of the bones in the neck (called cervical vertebrae) having malformations. This can be seen in conditions like Klippel-Feil syndrome.

Think of the last time you slept funny and woke up with a tight, painful (“twisted”) neck. In essence, you experienced to a small degree what torticollis is like.

What exactly is torticollis?

In torticollis the neck muscles get tight, short, and pull the head to one side. The muscles involved are the sternocleidomastoids. These are the muscles that run along the side of the neck (from the collarbone to the skull).

How is it diagnosed?

The diagnosis is completely clinical. An experienced doctor will be able to do an exam on the infant and determine that the baby has torticollis. Fancy/expensive imaging is not necessary to make the diagnosis. If the torticollis has been present for a while, the child may develop a flat head (on the side that he/she favors). The medical term for this is plagiocephaly. See Babies with Flat Heads.

How is it treated?

The good news is that congenital torticollis is treatable. The treatment generally involves frequent, gentle stretching exercises. This will loosen the tight muscles and strengthen the weaker muscles. Sometimes infants will be referred to a physical therapist for more intensive, targeted therapy. A physical therapist will work on range of motion and stretching exercises.

What can I do at home?

In addition to any exercises suggested by your doctor or physical therapist, making a conscious effort to reposition your baby to optimize neck movement can make a huge difference.

Feeds: Typically when babies feed, the neck is positioned toward the person feeding. If that happens to be the direction the child favors, try repositioning during feeds. Either flip the baby and feed bottles with the opposite hand or change holds (cross cradle vs. football) when breast feeding.
Holding: Try holding your infant in the other arms if the direction you currently hold the infant aggravates the torticollis.
Sleeping: Most babies will prefer to look into the room (rather than the wall). Position the baby so that the room direction makes the infant move the head in the unfavored direction. Your pediatrician may also have you position your infant slightly onto his/her side (again, forcing the infants head to the side that he/she doesn’t like). This should be done only under the guidance of your pediatrician as sleeping directly on the back without any sleep positioners is the safest sleep environment in terms of SIDS.
Playing: Using visual and verbal cues to try and get your infant to move his/her head in all directions.
Tummy time: Make sure your infant gets lots of tummy time to help strengthen shoulder and neck muscles. Aim for a short intervals (just a few minutes) multiple times a day. Your infants arms should be positioned at the shoulders (rather than down by his/her sides) during tummy time. This allows for the arms to help “push up.”

What’s the prognosis?

The prognosis for torticollis is great. Most kids will resolve with stretching, strengthening, and time.

What does the hips have to do with torticollis?

You may have heard mentioned something about hip issues with congenital torticollis. This is because 10-20% of kids with congenital torticollis also have hip dysplasia (malformed hip joints). I only mention this so you make sure your doctor does a hip exam at the same time he/she is checking out your child’s neck.

Are there other types of torticollis?

While I really only addressed congenital torticollis here, there are other types as well. “Acquired” torticollis develops later (that is, the child isn’t born with it) and may require various other interventions to address it.

If you think that your child has congenital torticollis, discuss it with your doctor. In the meantime, don’t freak out. It’s fixable.

Babies With Flat Heads

Posted on August 26, 2016August 17, 2020

Posted by Dr. Monica Wonnacott | August 26, 2016

There isn’t a week that goes by that I don’t see a baby with a flat head. The medical term for it is plagiocephaly (we like these fancy terms, it makes us feel smart). The truth is that flat heads are really common ever since we started having infants sleep on their backs (which decreases the risk of SIDS). In an infant, the head is relatively big and the skull isn’t fused (there are floating plates that make up the skull allowing for the head to mold as it is birthed out a small hole). When infants lay flat on their backs, the head molds flat.

There are really two types of flat heads–the ones you’re born with and the ones that develop. Your pediatrician can help you determine which type you are dealing with.

Craniosynostosis: Happens when the small plates of the skull fuse closed too early causing the head to grow misshapen. This can create all sorts of problems for the baby and requires surgical correction.
Positional plagiocephaly: Happens from pressure on one spot of the head causing it to become flat. Of the two types, this is far and away the most common. It happens when kids are “good sleepers” (so their heads are laying flat on the mattress for many hours) or favor the same side when they sleep. Usually the back of the head becomes the most flat. On occasion, the flattening will be to one side of the back which happens when a baby always sleeps with the head to one side. On occasion, the pressure from pushing the head flat will cause the front of the head to be asymmetric (e.g., the forehead or ear will protrude forward).

Prevention of Plagiocephaly

As is usually the case in medicine, prevention is the key.

As much as possible, get babies off of their back (when they’re awake).
Try and get plenty of tummy time.
Don’t let your baby sleep in the car seat (after the car ride). The car seat is really hard and can contribute to flat heads.
Alternate the direction your baby’s head is laying each night (one night, the head turned to the right, the next night the head turned to the left).

How is it diagnosed?

Plagiocephaly is a diagnosis that is made by simply looking at child’s head. Invasive labs and head imaging (xrays, CT scans, and MRIs) are not necessary. The potential exception to that rule may be in the case of craniosynostosis, but your pediatrician should be able to tell positional plagiocephaly from craniosynostosis by just looking. If a child has craniosynostosis (which gives a unique set of head shapes), the neurosurgeon (or craniofacial plastic surgeon) may order head imaging prior to surgery.

How is it treated?

Treatment of plagiocephaly depends on the cause. If it is due to premature fusion of the skull plates (craniosynostosis), then your child will need surgery to open the plates back up. If the cause is from positioning, your pediatrician may recommend repositioning your baby’s head when sleeping. If the cause is from torticollis (tight neck muscles) holding the head in one constant position, your baby will likely be referred to a physical therapist for stretching and range of motion exercises. In some severe cases, your pediatrician may recommend a specially fitted helmet to reshape the head. It is worth mentioning that treatment is most effective when initiated early (while that soft spot on top of the head is still large, so there is plenty of room for reshaping of the head).

Should I worry about it?

The most important thing to remember is that positional plagiocephaly is completely cosmetic. While you may not like how it looks, it will not cause brain damage. It will not affect your baby’s growth or development. As always, if you have questions or concerns, make sure and discuss them with your pediatrician.