What causes a flat head or Deformational Plagiocephaly?>

There are several causes of deformational plagiocephaly, and some of them can occur while the baby is still in utero.  Restricted space inside the mother’s womb can create excessive contact in certain areas of the baby’s head. This is often the cause of deformation in babies positioned in a breech position, cramped intrauterine space due to multiple births, or babies who spend excessive time with the head confined in the birth canal.
Other factors known to cause Deformational Plagiocephaly
The leading cause of deformational plagiocephaly is neck tightness caused by Congenital Muscular Torticollis or neck/trunk muscle imbalance. Torticollis is usually caused by an imbalance in the sternocleidomastoid and other neck muscles, which prevents full range of motion in the neck, forcing the child to turn or rest his/her head to the same side.  It is estimated that about 85% of the babies with deformational plagiocephaly also have some kind of neck involvement.

Torticollis

The head of a baby with torticollis is tipped to one side and rotated to the opposite shoulder, causing the head to consistently rest in the same position. The constant positioning of the head to the same side causes it to become flat in the back. Torticollis can also pull abnormally on the base of the skull and cause the ear on the same side as the posterior flattening to be pushed more forward than the opposite ear. In severe cases, the forehead can also be pushed forward on the same side, and the facial features including the eyes, cheeks, and jaw may not be symmetrical.

BEFORE OCCUPATIONAL THERAPY	AFTER OCCUPATIONAL THERAPY

          
 POSITIONAL
Another very frequent after birth cause of deformational plagiocephaly happens when the back of the baby’s head rests for prolonged periods of time against a hard surface like an infant carrier, car seat, swing, stroller or bouncy seat. Before 1992 babies were put to sleep on their tummies, which allowed the infant to naturally rotate his/her head from side to side, varying the amount of force on the back of the head. But since the early ‘90s, since the very successful “Back to Sleep” program started to get enforced by the medical community in general, all over the world in an effort to end Sudden Infant Death Syndrome (SIDS), infants now spend all night on their backs until they are able to roll and reposition themselves. It is estimated that the Back to Sleep program has reduced the incidence of SIDS by 40%, and it is very important to follow the regimen of putting your baby to sleep on the back. Unfortunately, the combination of the carriers we use to hold and position our babies during the day, and placing them to sleep on their backs all night have caused a sharp increase in the development of head shape deformities.

CATEGORIES OF HEAD SHAPE DEFORMITIES
There are three main types of positional head shape deformities:
PLAGIOCEPHALY
         

Deformational plagiocephaly is characterized by rear flattening, same side ear shift forward, and same side forehead prominence or bossing, and facial asymmetry. Deformation can occur in either a right or left orientation.
The first thing you can do is talk to your pediatrician about your baby’s head. The American Academy of Pediatrics suggests that pediatricians evaluate the baby’s head at each visit from the top, both sides, the front, and the back. The AAP also recommends that the physician talk to families about how to move the baby into a lot of different positions during the day, and stress the importance of “tummy time” whenever the baby is awake and supervised. “Tummy Time” is not only a good way to take pressure off the flattened areas, it also helps to build strong neck and trunk muscles, and will help your baby learn to roll, sit, and crawl when the time comes. If there is neck muscle imbalance or a delay in development, your pediatrician may refer your baby to a therapist for physical or occupational therapy.

Tummy time during play, under the direct supervision of a responsible adult, is the best way to assure that your child is stretching and exercising his neck and upper body.
The pediatrician may also recommend that a pediatric neurosurgeon or plastic surgeon assess your baby’s head shape to ensure that the sutures are all open and to check for any other skull shape disorders.
If your baby is diagnosed with deformational plagiocephaly, brachycephaly or scaphocephaly and is between the ages of 3 and 18 months, your physician may recommend treatment with a cranial remodeling orthosis. The STAR band is a plastic and foam device designed to gently correct your baby’s head.

 BRACHYCEPHALY
Deformational brachycephaly is present when the entire back of the baby’s head is flat (central flattening) and the head is very wide over the ears. The forehead is often bossed or prominent on both sides, and the posterior height of the head is excessively high. This deformity is the second most common type of deformity. Often babies with this problem have a history of excessive time in carriers, possibly due to gastric reflux or sometimes colic, or other medical conditions or circumstance that does not allow the baby to be placed on the tummy during daytime hours while awake and supervised.

	BEFORE  HELMET	AFTER HELMET TREATMENT

SCAPHOCEPHALY
Deformational scaphocephaly is characterized by a long and narrow head shape, sometimes caused by consistent positioning of the baby on its side. Like brachycephaly, scaphocephaly is a deformity of proportion. Premature babies are particularly prone to this deformity since their skulls are so moldable, and a side-lying position is often used in the Neonatal Intensive Care Unit (NICU) for easy access to monitors and other lifesaving equipment.

Cranial Synostosis
Craniosynostosis can cause head shape deformities similar to deformational plagiocephaly and deformational scaphocephaly, requiring surgery to remove the prematurely closed suture. This condition does not only distort the head shape, but may pose health risks to the child if not corrected with surgery. The craniofacial specialist will perform a medical examination of the head shape and face of your baby, and may order an X-ray, 3D-CT scan or MRI to rule out the possibility of craniosynostosis. Even though it is much less common than non synostonic deformations, it requires prompt and expert attention. After surgery, the craniofacial surgeon may order a cranial remolding orthosis for protection of the incision site and also to acquire additional correction of the head shape and/or proportion.
Depending on which suture or if multiple sutures are involved, that is the shape the skull will assume. Helmet therapy is not indicated when the cause of the misshapen head is cranial synostosis. That is why it is very important to have your child checked by a craniofacial surgeon, which could be a pediatric neurosurgeon or pediatric plastic surgeon, to accurately diagnose and treat the problem. It is not recommended to have your child treated for helmet therapy if not properly diagnosed and followed by a cranial specialist.

Coronal Synostosys
Coronal synostosis could present unilateral or bilateral.  It involves the forehead and the supraorbital region, in other words the rim between the top of the eye and the eyebrow creating what is called a “harlequin” look to the involved eye.