The Misshapen Head

The evaluation and management of infants with potentially misshapen heads presents many challenges. Diagnostic dilemmas for the pediatric primary care provider can be significant. Is a particular infant’s head shape normal or abnormal? How does one define geometric and anthropomorphic features? Does the head circumference measurement bear any significance? Should skull radiographs be obtained? What about computed tomography scans? To whom should this infant be referred: a neurosurgeon, plastic surgeon, physical therapist, or geneticist? And, perhaps most difficult, what does one tell the parents?

Pediatric subspecialists caring for these patients must be dedicated to a comprehensive and compassionate multidisciplinary approach. Primary objectives include the early and thorough evaluation of the suspected cranial abnormality and its optimal management, resulting in the greatest patient benefit at the lowest risk. Establishing an effective line of communication among family and health care team members is imperative. A rewarding part of our jobs as care providers is the alleviation of fear and anxiety that haunts parents who believe their infant may be “deformed.” Thus, clarification and education become paramount.

After the introduction of the “Back to Sleep” program for the prevention of sudden infant death syndrome, evaluation of the misshapen head has become a very common referral problem for pediatric neurosurgeons. The vast majority of these represent positional plagiocephaly—flattening of the occipital region produced by chronic pressure effects on the calvarium in infants who lie supine. Because the cranial sutures remain open in this entity, nonsurgical management is generally highly effective. This includes positional alteration; physical therapy if any underlying …

Address correspondence to Todd A. Maugans, MD, University of Vermont College of Medicine, Fletcher Allen Health Care, Pediatric Neurosurgery, Fletcher 5, Burlington, VT 05401. Email: todd.maugans{at}vtmednet.org