NICU Babies at Risk for Plagiocephaly

Who is at risk for plagiocephaly or head flattening?  The answer is every baby regardless of whether they are born vaginally, via c-section, full term or premature.  It is very important to be aware that gravity starts acting on a baby at birth making him or her susceptible to flattening of the skull right away.  Changing a baby's head position throughout the day is essential to ensure a rounded skull appearance.  The variety not only helps head shape, but it also aids in the increasing the tensile strength of the bone.

Often times when babies are born prematurely, they can spend anywhere from a few days to several weeks in the neonatal intensive care unit (NICU) depending on how premature they are.  Along with the increased level of prematurity comes the amount of intervention, tubes, machines, etc. hooked up to the baby.  Most of the time, all of the equipment is placed on one side of the isolet or bed. Potentially, a baby can spend days with his or her head turned to the same side.  I see many premature patients in the clinic, especially twins, for plagiocephaly because of lengthy NICU stays.  It is the nature of the situation.  I am not sure how feasible it is to move the equipment from side to side of the isolet, but it definitely would be helpful in ensuring round head development in our tiniest babies.  And if moving the equipment is not an option, why not move the baby from the head of the bed to the foot of the bed with each diaper change so that his or her head is turned the opposite way on a regular basis.

Having two premature babies myself, I know how important it is to keep the baby calm, reducing the amount of activity to a minimum for oxygen saturation and heart rate, but a little long term planning would really benefit these babies once they get out of the NICU and move on with development.  Remember, it is always easier to prevent head flattening than it is to correct it.

Gravity, Pressure and Plagiocephaly

When treating plagiocephaly, parents are instructed to keep their baby off of the flattened spot as much as possible to prevent worsening.  Often, parents translate this to keeping the baby upright as often as possible with no pressure on the head at all in hopes that this will round out the head shape.  One frequent question I field in my practice when dealing with babies who have plagiocephaly is, "If I just keep him off his head, it will round out?"  It would seem a logical solution, but in fact, allowing the baby to lay on the rounded area is actually more beneficial.  The brain grows in the path of least resistance, therefore, if you put pressure on the right side, the brain "moves" left.  The scenario I use for parents is this: think of a tennis ball in a water balloon.  If you put pressure on one side of the balloon, the ball shifts to the opposite side.  When the soft spot and sutures are still open, the head is very much the same way albeit not as pliable.  Therefore, placing the baby on the rounded part of the skull actually acts to shift the head to a more rounded position.  This is same concept of cranial remolding helmets.  These orthotics hold the high points (rounded parts) of the skull and take all pressure off of the flattened areas to encourage brain growth in the desired direction, simply put.  Conservatively, placing the baby's head on the rounded area follows the same concept.  

In addition, according to Wolf's law, bone will adapt to the load placed on it and actually make structural changes to become stronger the more load it is experiencing.  In essence, the skull gets stronger by having the baby lay on it.  This is important in protecting the brain making lying on a firm surface essential.  Prolonged lying on soft surfaces will thwart this process of strengthening of the bone.  

Once the soft spot and sutures of the skull close, the head shape will remain unchanged, for the most part.  Eighty percent of head growth occurs in the first year of life making this the perfect window of opportunity to ensure a nice rounded head for the future.  The best practice is to place your baby a variety of positions on a firm surface for a rounded skull and a strong skull.  If high points or rounded areas exist, think of the path of least resistance and encourage the baby to lay on those areas of the head.