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.  

How to Prevent Head Flattening and Shortened Neck Muscles in Your Infant

I thought it most beneficial to post a simple check list of the most effective ways to prevent flat spots on the head or misshapen head (plagiocephaly) and shortened neck muscles (torticollis) in your infants. 

*Avoid prolonged use of car seats, bouncers, swings, and the like.

*Only use car seats in the CAR not as a place to sleep at home.

*Allow baby plenty of play time lying flat on the floor, crib, bassinet, play yard.

*Tummy Time, Tummy Time, Tummy Time!

* Carry your baby in your arms as often as possible.

*Make sure your baby is turning the head to both directions daily.

*Be safe!  DO NOT PUT soft, plush items in the baby's sleep area to reduce the risk of suffocation!

 

What SIDS is NOT!

I had the distinct opportunity to attend the Collaborative Improvement and Innovation (COIN) meeting for the Safe Sleep initiative in Alabama this week and met some motivated leaders in the field who are passionate about making a difference in the arena of protecting infant life.  This initiative will be collaborating with the Safe to Sleep campaign through the National Institute of Health.  Encompassing 13 states, the five areas of focus for COIN are 1) Safe Sleep 2) Perinatal Regionalization 3) Smoking Cessation 4) Interconception Care and 5) Elective Deliveries before 39 weeks.  All five focus areas have a single goal: lowering the infant mortality rate- saving babies' lives.

During the meeting, a common theme resounded.  The second leading cause of death in children under the age of 18 years old is sleep related deaths.  The first leading cause is attributed to vehicle accidents.  Astonished?  I am, too!  What that means is in the state of Alabama the second leading killer of children is PREVENTABLE!  In order to break this down, I feel it is first essential to explain and over explain what SIDS is not so that people realize they can prevent infant death....they can save babies' lives. 

SIDS is the unexplained death of an infant under one year old diagnosed after autopsy, death scene investigation and child/family medical history review.  If the cause of death remains unclear or unknown it is labeled SIDS.  I bring this up again because many people think of any infant death as SIDS and that there was "nothing that could prevent it". If it is a true SIDS case and all of the requirements are met, then yes, you can't prevent it when you don't know happened.  The actual SIDS rate is very low.  However, if the death was preventable, IT IS NOT SIDS!

What is preventable?  Sleep related deaths.  And because they are preventable, they are NOT SIDS.  A sleep related death is when a baby suffocates laying in an adult bed.  A sleep related death is when a baby is trapped under another child and smothered during sleep.  A sleep related death is when a baby is left to sleep in a car seat, his or her head falls forward and cuts off the airway causing the baby to stop breathing.  A sleep related death is when a baby slips between the crib and the mattress because it is not properly fitted and becomes trapped.  A sleep related death is when a baby is smothered by pillows, blankets and stuffed animals in the crib.  It is gruesome, it is gory, but it is absolutely necessary for all of you to understand you can prevent sleep related deaths.  And it is also essential to understand that we are not fighting SIDS here, we are fighting accidental deaths. 

I firmly believe people have it in their minds that sudden infant death has us all clutched in its grasp with no recourse.  It is simply not true.  We must, MUST understand the distinction between SIDS and a sleep related death if we are ever going to move forward in lowering the infant mortality rate.  What you know can save your baby's life. 

It is a grave injustice for parents to be given a SIDS diagnosis for the death of their infant when in fact it was a sleep related death.  This only puts future children at risk for an accident of the same kind.  Being told "there was nothing you could have done, it was SIDS" when it was actually an accidental suffocation, entrapment or parent overlay will do nothing to help those parents.  We have a responsibility as a medical community to be honest and upfront so parents can not only protect their own children, but also become advocates for other parents as well in safe sleep practices for infants. 

Safe sleep means:
1) An infant should have their own sleeping environment with a firm sleep surface (crib, play yard) where they sleep alone
2) Nothing soft or plush should be put in the baby's sleeping area like heavy, thick blankets, pillows or stuffed animals
3) A baby should not sleep in an adult bed, on the couch or in a recliner due to the risk of suffocation
4) A baby should not sleep in a car seat, swing or bouncer due to the risk of closing off the airway

Be safe out there and know that you can protect your baby's life! 

Plagiocephaly and Craniosynostosis

I'd like to share a case study of an infant I have been seeing for ~5 months.  He was first referred to me in the clinic for flattening of the back of the skull (positional plagiocephaly) at 4 months old.  We started on a stretching program to stretch his neck muscles that were tightened (torticollis) and a positioning program to correct the flattened area of the skull.  He made a full recovery from the tightened neck muscles and his head rounded out to within a few millimeters difference from left side to right side.  A few months later, he returned for developmental delay due to a weak trunk and not sitting.  Through the course of treatment, his mother, pediatrician and myself noted a protrusion on his forehead that was becoming more prominent.  After a trip to Vanderbilt to consult with a cranio-facial surgeon, he was diagnosed with single suture craniosynostosis.  There exists in the skull a series of sutures that are open at birth to allow an infant to pass through the birth canal.  These "soft spots" remain open through the first year to accommodate the growing brain and fully fuse by adulthood.  If any one of these sutures closes prematurely, it is termed craniosynastosis.

After some research, it became evident that although craniosynostosis is rare (reports stating 1 in 2000 to 1 in 4000) it is important for parents and physical therapists alike to be aware of it when it comes to plagiocephaly (misshapen head).  It is therefore encouraged for pediatric physical therapists to check whether the soft spots are still open with each baby with a diagnosis of plagiocephaly.  This is especially true with babies with a diagnosis of brachycephaly- a type of plagiocephaly.  Fusion of the metopic suture (the suture on the forehead) causes a triangular shaped head with a narrow forehead and wide back of the head which is also the cranial shape with brachycehpaly.  In my travels across the country, I have spoken with many PT's and orthotists alike who say "It is more difficult to treat a baby with brachycephaly with a cranial remolding helmet," with some claiming very little success with this head shape type.  Perhaps it is actually a single suture craniosynostosis of the forehead suture (metopic) rather than a failure of the helmet in these cases. 

Every tool we can put in our case is a benefit to a child.  If you have a story you would like to share on this topic, I'd like to open it for discussion.   

Press Release

The National Institute of Health is pleased to announce the launch of the Safe to Sleep Campaign which enhances the previous Back to Sleep Campaign of 1994.  This campaign is different from the original program in that it expands the focus from only Sudden Infant Death Syndrome (SIDS) to all sleep-related, sudden unexpected infant deaths.  As part of the initiative, the NIH has announced Safe to Sleep Champions in the states with the highest numbers of SIDS and other sleep-related deaths to promote the new campaign.

Stephanie Pruitt, Pediatric Physical Therapist and author of The Truth About Tummy Time: A Parent’s Guide to SIDS, the Back to Sleep Program, Car Seats and More has been named a Safe to Sleep Champion by the National Institute of Health as a spokesperson for the North Alabama region.  Pruitt, along with 35 other Champions in the states of Alaska, Arkansas, Delaware, District of Columbia, Georgia, Iowa, Kansas, Kentucky, Louisiana, Michigan, Mississippi, Missouri, Montana, North Carolina, Oklahoma, South Carolina, South Dakota, Tennessee, West Virginia and Wyoming will be promoting the Safe to Sleep Campaign in various media outlets throughout the month of October, National SIDS Awareness month, to spread the word about the new campaign.

“What you know could save your baby’s life”, Pruitt says stressing that a safe sleep environment can determine your baby’s survival.  “Although the SIDS rate has declined in recent years, the rates of other sleep-related deaths like suffocation, accidental strangulation and entrapment have increased making this program so important for parents and caregivers of infants up to one year old.” 

The main message of the new campaign is a safe sleeping environment.  This includes a separate sleep environment for the infant (like a crib, bassinet or play yard) with a firm mattress that fits the bed snugly.  Infants should not be placed to sleep in an adult bed due to the risk of overlay, entrapment or suffocation.  All soft, loose items like stuffed animals, thick, heavy blankets or pillows should not be placed in the sleeping area as they pose a risk of suffocation.   The American Academy of Pediatrics recommends placing the baby on the back to sleep for every sleep in a safe sleeping environment. 

For more information on the Safe to Sleep campaign, visit www.nichd.nih.gov/SIDS

For more information on The Truth About Tummy Time A Parent’s Guide to SIDS, the Back to Sleep Program, Car Seats and More visit www.abouttummytime.com  

New AAP Recommendations for Safe Sleep

It is with great pleasure that I am posting the new American Academy Recommendation for infant sleeping.  The policy statement released in October 2011 is now making its rounds in the medical community with the NICHD launching the Safe to Sleep campaign in the near future.  I am almost moved to tears to read in the opening paragraph of the policy statement, "The AAP, therefore is expanding its recommendations from focusing only on SIDS to focusing on a safe sleep environment that can reduce the risk of all sleep-related infant deaths, including SIDS."  Also in that opening paragraph is, ""...other causes of sudden unexpected infant death that occur during sleep, including suffocation and asphyxia, and entrapment...have increased in incidence, particularly since the AAP published its last statement in 2005".  I am SO excited to hear about the newly expanded campaign as it makes all the effort of educating about safe sleep for the last several years worth it!  

The following are the new recommendations:

1) (not surprisingly) Back to sleep for every sleep
    - Once an infant can roll from back to stomach and stomach to back, the infant can be allowed to remain in the sleep position that he or she assumes.

2) Use a firm sleeping surface- a firm crib mattress, covered by a fitted sheet
    - infants should not be placed for sleep on beds because of the risk of entrapment and suffocation
    - portable bed rails should not be used because of the risk of entrapment and strangulation
    - Sitting devices, such as car seats, strollers, swings, infant carriers and infant slings are not recommended for routine sleep

3) Room-sharing without bed sharing is recommended
    - infant crib, portable crib, or bassinet should be placed in the parents' bedroom.  This arrangement reduces the risk of SIDS and removes the possibility of suffocation, strangulation, and entrapment that might occur when the infant is sleeping in the adults' bed.
    -devices promoted to make bed sharing "safe" (co-sleepers) are not recommended

4) Keep soft objects and loose bedding out of the crib to reduce the risk of SIDS, suffocation, entrapment and strangulation

5) Pregnant women should receive regular prenatal care

6) Avoid smoke exposure during pregnancy and after birth
    - Smoking in the infant's environment is a major risk factor for SIDS

7) Avoid alcohol and illicit drug use during pregnancy and after birth

8) Breastfeeding is recommended

9) Consider offering a pacifier at nap time and bedtime

10) Avoid overheating

11) Infants should be immunized in accordance with recommendations by the AAP and the CDC

12) Avoid commercial devices marketed to reduce the risk of SIDS

13) Do not use home cardiorespiratory monitors as a strategy to reduce the risk of SIDS

14) Supervised, awake tummy time is recommended to facilitate development and to minimize development of positional plagiocephaly   :)

The list goes on for a total of 18 recommendations.  For a complete view of the policy statement click here.