PEDIATRICS Vol. 111 No. 4 April 2003, pp. 918
Management of Infants With Potentially Misshapen Heads
To the Editor.—The evaluation and management of infants with potentially misshapen heads need not present "challenges" and usually need not involve a pediatric subspecialist.1
As indicated in the accompanying article by Jimenez et al,2 a long narrow head with a "keel" is caused by sagittal stenosis. Unilateral or bilateral coronal stenosis is readily recognizable based on the craniofacial deformities they produce. The closure of the sutures can be confirmed radiologically and referred to a pediatric neurosurgeon.
Unilateral or bilateral lamboid stenosis is, on the other hand, very rare and presents with unilateral or bilateral flattening of the posterior quadrant of the head. A far, far more common cause of occipital flattening is positional plagiocephaly attributable to the "Back to Sleep" program. The same flattening can also be seen in hypotonic infants who do not move their heads; in those with substantial developmental delay; or asymmetrically in infants with torticollis. Such infants do not need to see a pediatric subspecialist. They can and should be managed initially by their physician.
Changing the child’s position slightly during naps and sleeping can correct the positional problems.
Pediatricians or other physicians see these infants frequently during the first months of life. If they merely looked at the back of the child’s head during these visits and if flattening was seen or suspected had the mother placed a rolled towel under the shoulder of the back-sleeping child, the pressure of the weight of the head would be shifted to the posterior quadrant of the head. Switching the towel from side to side would allow the child’s head to round up. Alternatively, many therapists know how to carve, out of foam rubber, a pillow that redistributes the weight of the head and is comfortable for the child. The costs are minor and the results are superb.3 Thus, the negative cosmetic effects of the "Back to Sleep" program could be ameliorated or prevented without the expense of radiographs and subspecialists.
John M. Freeman, MD
Department of Neurology and Pediatrics
Johns Hopkins Medical Institutions
Baltimore, MD 21287-7247
Benjamin S. Carson, Sr, MD
Department of Pediatric Neurosurgery
Johns Hopkins Medical Institutions
Baltimore, MD 21287-7247
REFERENCES
- Maugans TA. The misshapen head [commentary]. Pediatrics.2002; 100 :166 –167
- Jimenez DF, Barone CM, Cartwright CC, Baker L. Early management of craniosynostosis using endoscopic-assisted strip craniectomies and cranial orthotic molding therapy.
Pediatrics.2002; 110
:97
–104
[Abstract/Free Full Text] - Carson BS Sr, Munoz D, et al. An assistive device for the treatment of positional plagiocephaly. J Craniofac Surg.2000; 11 :177 –183[Medline]
In Reply.—
I appreciate the insightful commentary by Drs Freeman and Carson. Indeed, the vast majority of "misshapen heads" encountered by the practicing pediatrician are affected by positional plagiocephaly (also called deformational plagiocephaly). Classic risk factors for this entity include abnormal uterine lie, multiple gestation, abnormal cervical muscular balance (torticollis), and, most commonly, excess pressure on one side of the occipital bone in the infant who is maintained in the supine position for prolonged periods of time. Any infant with such risk factors and unilateral flattening of the occiput associated with an apparent anterior displacement of the ipsilateral ear and frontal bone almost certainly manifests this condition. Absence of palpable ridging over the lambdoid suture is further confirmatory. It has been suggested that as many as 20% of infants will develop this condition, secondary to a high compliance rate with the "Back to Sleep" program.
I concur with the authors that most infants will be affected mildly and not require any radiologic evaluation or subspecialty consultation. The astute and appropriately educated pediatric health care provider can readily identify and manage such patients. As an academic pediatric neurosurgeon, I have taken an aggressive role in the education of primary care physicians to this end. Indeed, most pediatricians and family practitioners feel comfortable managing the mild cases. Repositioning methods such as those outlined by Drs Freeman and Carson can be highly successful in improving the cosmetic deformity. Some degree of residual flattening, however, should be expected in nearly every case. The final degree of deformity appears to be stabilized between 2 and 3 years of age.
A pediatric craniofacial specialist—neurosurgeon or plastic surgeon—is frequently consulted for patients presenting with more significant deformities and patients with unusual asymmetries. In many cases, repositioning efforts have been carried out unsuccessfully. Such patients become candidates for active remodeling via the application of cranial orthoses. As iterated in my initial commentary, surgery is never indicated for these patients.
I offer a final comment about the authors’ recommendations: repositioning efforts require significant energy in diligence on the part of all care providers, not just the mothers of the affected infants. As the father of a child so affected and managed, I can personally attest to this fact.
Todd A. Maugans, MD
Departments of Surgery (Neurosurgery), Pediatrics and Family Practice
University of Vermont College of Medicine
Burlington, VT 05401
PEDIATRICS (ISSN 1098-4275). ©2003 by the American Academy of Pediatrics
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