Flat Spots

Carol Gray Talks About Plagiocephaly and CSTI see lots of babies with flat spots on their heads (plagiocephaly) in my practice. Some of them come diagnosed, some not.

The most common garden variety is the broad flat spot on the back of the head – an artifact of the Back to Sleep Program and time spent in car seats, baby seats and swings that have a flat, firm surface. My mantra is: Back to sleep, tummy for play, car seats only for car rides and in arms or slings the rest of the time. Of course, this doesn’t mesh well with what most Americans actually do with their babies – especially the car seat part.

The (controversial in my world) Back to Sleep program has arguably saved the lives of hundreds of babies. Although, many people feel that the drop in the SIDS rate has more to do with medical examiners requiring autopsies on babies who are suspected of having died from SIDS and subsequently determined to have succumbed to something else. These are babies who would have previously been included in SIDS numbers. But, I digress…

The second most common kind of plagiocephaly I see is the flat spot on one side of the back of the baby’s head. Usually this is caused by the things listed above with the addition of torticollis to the picture. It is common for me to meet a baby with this kind of plagiocephaly after the parents notice that the baby is developing a trapezoid shaped face. They want to know if I can fix the baby’s face, but first we need to “un-fix” the baby’s neck.

Torticollis (it used to be called wry neck syndrome) develops typically in utero when for some reason the baby has a lack of space or lack of ability to move around freely. The baby’s neck is flexed or rotated to one side and pairs of muscles develop longer and over stretched on one side and shorter and contracted on the other. The actual in-utero conditions that contribute to this include being one of a pair of twins, short umbilical cord, low amniotic fluid, restrictions in mom’s abdominal organs, restrictions, scarring or anomalies in mom’s uterus, restrictions in the ligaments that support mom’s uterus, the actual list is longer and sometimes it just happens.

These babies get born and nobody notices that Junior only likes to turn his head one way. Or if adults do notice it, they don’t realize that it’s a problem. Several weeks later, Junior has a trapezoid-shaped face.

There is a lot that CST practitioners can do to address the contracted, shortened parts of this neck condition. I give parents information about how to alter their care-giving and play activities so babies can develop balanced length and strength, especially in the weakened, over-stretched muscles.

It’s important to remember that babies’ heads and bodies grow into available space. If that space is hard, restricted and asymmetrical, the paired bones and body parts that would ordinarily be mirror images of their counterparts will develop differently.

As CST practitioners, we can make sure that all these parts move independently of their neighbors. With time for more growth into yielding, symmetrical space, things will balance out. Actual symmetry varies, of course.

I am increasingly seeing babies who wear special corrective helmets or strap devices that physically restrict the growth of the prominent cranial bones and allow unrestricted growth of the ones that are less prominent. It’s important to know that these devices correct cosmetic problems. Parents have such an unlimited array of pressures and information to consider when they are making decisions about their kids…

Of course, I’m happy to treat the helmeted babies. They really need CST. It’s good to check in and make sure the cranial bones are moving independently of their neighbors the way they should. Helmeted babies really need the work I do.

The next most common variety of head-shape issue is persistent sutural overrides. Sutures are the joints between the bones in the skull. The cranial (skull) bones often override (overlap) each other in the birth process. This is completely normal. Overrides should (and usually do) resolve as soon as the baby is born. It may take hours, days or weeks for the untrained person to recognize that the overrides are gone (the cone-head can last a while due to swelling in the soft tissue), but pretty much they resolve on their own. If they don’t resolve on their own, I gently move them away from their neighbors. Because I’m a midwife, I have many opportunities to do this right away. The earlier we address a persistent sutural override, the better. Of course, isn’t that true of almost everything?

The next most common head-shape issue has its roots in the space restrictions that contribute to torticollis. Sometimes during fetal development whole bones get jammed up against something hard – part of mom’s pelvis, mom’s rib, etc. The bone in question develops a dent, ridge or groove. This is also a common origin of so-called club foot.

I once treated a baby (one of a pair of twins) who had undergone surgery to correct a depressed skull fracture – presumed to be a birth injury – that turned out not to be a fracture at all. The baby had a dent in one of the flat bones in her skull where it had been lodged against her mother’s rib for many weeks. It had simply developed that way.

Last, but not least we have cranial synostosis – actual (the MD’s would say premature) fusing of sutures. I see babies with this condition in my practice, too. Some of them have been misdiagnosed. I can get them to move because they were actually persistent sutural overrides or oddly shaped cranial bones.

The surgery for cranial synostosis can be harsh. Sometimes the surgery has to be done in order to make room for the developing brain and for the child to have a shot at normal neurological development. Other times the surgery is cosmetic. Without the surgery a child may be subjected to being called “pinhead” or worse throughout his/her school career.

I have treated kids with this condition whose parents opted not to have the surgery. Foregoing surgery is more common in Europe than the US. When parents decide to operate it is incredibly helpful for the kids to get CST before and after the surgery.

Hopefully this wasn’t too technical for a general audience…

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