If Not Craniosynostosis??

Positional Plagiocephaly

 What is Positional Plagiocephaly
Each infant's skull is made up of a number of bones that remain free floating joined together by sutures that remain open and stretchy to allow the skull to mold for birth as well as allow the expanding brain to grow.
All infants have a molded, abnormal head shape shortly after birth but it should correct within the first six to eight weeks following birth.
Any abnormal head growth past this time should be referred to a craniofacial specialist or neurosurgeon for evaluation. Positional Plagiocephaly or craniosynostosis could be the culprit. A qualified specialist will know the difference. 
As a parent the most important thing I will continue to stress throughout this website is to follow your gut instinct. If you feel something isn't right with your child despite conflicting opinions you are your child's best advocate. Don't be afraid to push for answers and seek second sometimes third opinions.
I will use this page to talk about Positional Plagiocephaly and the next for Craniosynostosis.
Thank you To Alexanderas PHATE who I consulted for further info on Positional deformity.

The Term Positional was adapted to differentiate from true Synostosis. With true Synostosis one or more of the skull's sutures prematurely fuse. The internal fusion is the result of skull deformity. In the case of positional deformity there is NO fusion of any sutures  and an outward pressure is the cause of any abnormality.

3 Types of Positional Abnormalities
Postional Deformity

I have titled this page Positional Plagiocephaly because that is the most common form of Plagiocephaly.  Any website search engine for Positional Plagiocephaly should lead you to information on one of the 3 forms of positional abnormalities.  However, there are three types of headshapes associated with positional deformity. 

Postional Plagiocephaly:
positional plagiocephalyOne Side of the back of the head is flattened and is most commonly accompanied by a prominent(bossed) forehead opposite  the side of the flattening. The ears will also be misaligned with the ear on the affected side most commonly being pulled forward and down & can also appear larger than the unaffected ear.  Facial asymmetry will more than likely be present and can include:
  • a fuller cheek on the effected side
  • a more prominent(bossed) appearance of the effected side of the face
  • a jawbone that is tilted
  • one eye that appears displaced or mismatched in size.

Positional Brachycephaly:
Positional BrachycephalyThe entire back of the head is flat in the back. The entire head can appear wide and flat. There may be a bulging behind both ears as well as a fuller more prominent forehead. Positional Brachycephaly is most often present when a child sleeps entirely on the back of his/her head.

Positional Scaphocephaly:
Positional Scaphocephaly The head is long and narrow. Prematurity or positional molding from a breach infant's head being stuck under the mother's ribs in utero can be contributing factors for scaphocephaly.

 I have heard that this is only Cosmetic, should I be concerned?
Any concern for your child's headshape should be discussed with a craniofacial specialist. They are the only ones who can dismiss or diagnose either Craniosynostosis or Positional deformities.
A lot of doctors and even the media have, in the past, falsely disregarded concerns for headshapes as only a cosmetic worry.  With Positional abnormalities brain growth is not restricted and is not thought to cause any kind of damage to the brain. However, increasing evidence is finding that many problems can arise(especially when facial asymmetry is present).
  • possibility of psychological disturbances due to an abnormal appearance that can last well into childhood and even adulthood(remember what can be covered up with hair as a child might later reveal itself as hair thins with older age. As parents we tend to forget our boys might be bald one day.)
Lastly, the the American Medical Association defines a cosmetic procedure as one that changes a normal structure of the body in order to improve appearance. While defining a reconstructive procedure as one performed on an abnormal structure of the body to improve function, or return it to normal.

What Causes Positional Abnormality?
  • In utero constraint: multiple babies in one pregnancy, small maternal pelvis,
    inappropriate amount of amniotic fluid, or breech position, can all cause constriction in the womb while the fetus is still developing. This constraint can lead to positional abnormalities.
  • Prematuraty: a premature infant has a very soft and malleable skull which makes it more susceptible to outward molding.
  • Back Sleeping: in 1992 the American Academy of Pediatrics launched the "Back to sleep Campaign" which significantly dropped the amount of infant mortality due to SIDS(sudden infant death syndrome) yet it significantly raised the amount of positional abnormalities. Parents were not given enough information regarding back sleeping and how the infant’s sleeping position should be alternated to prevent constant sleeping on the same side, nor were parents informed of the importance of “tummy time” during play. Consequently, because of the fear that many parents have regarding SIDS, many infants spent almost 100% of their time on their backs. Between infant car seats, infant carriers, bouncy seats, infant swings and sleeping on a mattress at night an infant spends little or no time without external pressure applied to the back of the head which leads to a high susceptibility to Positional Plagiocephaly.
  • Congenital Muscular Torticollis (CMT) aka Tort: is a condition that is usually caused by one or more of the neck muscles being twisted or shortened. Without diagnosis and physical therapy to work and stretch the neck muscles an infant will tend to tilt or turn their head in one direction. The tendency to lay in the same direction can cause flattening on one side of the back of the head.

How Is Positional Deformity Diagnosed?
An appointment with an Experienced Craniofacial Specialist needs to be made. Sometimes CT Scans & MRIs need to be ordered. As more is understood about positional deformity a Craniofacial specialist can tell upon physical assesment if your child's condition is in fact positional or craniosynostosis.

"Wait MRIs? CT scans? I discussed my concerns with my child's pediatrician and they want to send for an xray."
Although Xrays will show if sutures are present they will not show the suture in enough clarity to catch if fusion has begun or not. Only a craniofacial specialist should be allowed to diagnose or dismiss positional deformity or craniosynostosis.

What Are The Treatment Options?
The first line of defense is to get the baby off the flat area of the head as much as possible. Remember "Back to Sleep and Tummy To Play". Limit time spent in swings, strollers, and carseats.
A few good suggestions
  • reposition the baby when he/she sleeps to keep him/her off the flat spot of their head while still keeping them on their back to sleep. 
  • invest in a front carrier pack instead of a stroller
  • place toys or mobiles to attract baby's attention and turn off the flat side
  • my personal favorite "Boppy® pillow time"
Repositioning works best if the deformity is caught before six months of age.(Repositioning will not work with Craniosynostosis because a fused suture is not open and pliable no amount of outward pressure will move a suture that is fused.)
If you believe your child has tort a qualified specialist can work you through repositioning and stretching exercises.

Okay so what if repositioning does not work ? What are my options if the positional deformity is severe?
First let me put your mind at ease. In cases of positional deformity(unlike true Craniosynostosis) surgery rarely needed when caught before the first year of age. Best results for remolding occur before the one year birthday because 80% of the skull's growth takes place in that time period.
The debate on the need for treatment can be a bit conflicting between doctors. Some insist that positional deformity will correct on its own once the infant can move around more and sit up which gets pressure off their head as it grows. This can be true of mild cases but moderate to severe positional deformity will need intervention for correction.
In these Cases Molding Helmets can be used.
A molding helmet works best when started around 5 months of age and some can be used as late as 18 months of age.
The original molding helmet was introduced in 1979 with the basic idea that if you surrounded an asymmetrical skull with a symmetrical helmet the skull would then grow into the more "normal" and symmetrical shape. Although, Archaeological diggings in burial sites in Cebu, Samar, Bohol and other places in the Philippines have found dozens of skulls that clearly show the physical effects of molding or binding.
An alternative technique to molding helmets is Dynamic Orthotic Cranioplasty(DOCband®) which is a more proactive approach to correction.  The design of this helmet provides a gentle pressure to the area where growth is not wanted while leaving space for the skull to grow in areas where it is wanted. With this technique the child is seen on a weekly to biweekly basis to have adjustments made to the band to ensure proper growth of the head and optimum correction of the deformity.
There is a large variety of helmets and bands available today but many take on this approach first developed with the DOCband®. Also, they are all light-weight, and all are custom made to fit each infant's head. Your specialist will be able to help you decide which helmet or band to use although I encourage parents to be sure to thoroughly research each style offered to find out the success rate.

How Long will my baby be in this helmet?
Helmets are designed to be worn 22 to 23 hours a day with one or two hours off for cleaning and resting the skin. The amount of months a helmet will be needed is all dependant on the severity of the child's positional deformity. Some cases have been minor enough to have treatment completed in 2 to 3 months while others have been severe enough to require a second helmet and treatment. The average time is typically 2 to 6 months.
Leigha-DOC band
 Leigha had a DOC band for post-op molding
Provided by Cranial TechnologiesWe were very happy with the rusults of this helmet.

Where Do I get More Information?

Note: Helmets can be tiresome and exhausting with biweekly check ups, adjustments, and having your child have to wear it 22-23 hours a day. But you as a parent can have lots of fun decorating and personalizing your child's helmet, as an artist I did my own and changed out the theme weekly but there are two companies I know of that can customize for you.
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