New Insights Into Classification and Risk Factors for Plagiocephaly

Newswise — The recommendation to lay babies on their backs to sleep has reduced the rate of sudden infant death syndrome (SIDS), or "crib death." However, recent studies suggest an unintended consequence: an increased number of infants with flattening of the back of the skull, termed "positional plagiocephaly."

A new study in the Journal of Craniofacial Surgery seeks to identify risk factors for positional plagiocephaly, while an article published earlier this year proposes a standard classification for assessing the severity and necessary treatment for this increasingly recognized deformity.

In the November issue, Dr. Mutaz B. Habal and colleagues of Tampa Bay Craniofacial Center in Tampa, Fla., present a preliminary study of risk factors for plagiocephaly. Dr. Habal is also Editor-in-Chief of the Journal of Craniofacial Surgery.

Detailed interviews with the parents of 37 infants evaluated for skull flattening found no clear or consistent pattern of risk factors. Few of the mothers were exposed to any chemicals or other substances that might lead to softening of the cranial bone or other bone abnormalities. None of the parents and none of their other children had had plagiocephaly.

Although no risk factors were identified, some interesting patterns emerged. Risk may have been higher for infants born to mothers in their thirties, while many of the mothers either smoked before or during pregnancy or lived with a smoker.

In addition, many of the mothers drank a lot of caffeine-containing beverages, especially cola drinks and coffee, while pregnant or breast-feeding. Some previous studies have linked high caffeine intake to reduced bone density in women.

For now, however, Dr. Habal and colleagues stress that the associations are interesting trends only: "[T]he data do not identify or eliminate a single rational cause of the softness of the bone in the affected infants' skulls."

In the May issue, Dr. Louis Argenta of Wake Forest Baptist Medical Center, Winston-Salem, N.C., outlined a classification system to guide evaluation of infants with possible skull flattening. Dr. Argenta believes that such a standard system will promote consistent evaluation of plagiocephaly while guiding treatment choices.

For infants with only mild skull flattening—designated "class I" in Dr. Argenta's classification—positioning devices to move the infant off his or her back may be the only treatment needed. For those with more severe, "class II" or higher flattening, a special helmet device may be used to remodel the skull gradually. The classification can also help to monitor improvement in the infant's head shape during treatment. If plagiocephaly does not improve or becomes more severe, additional evaluation may be needed.

Dr. Habal and his fellow researchers underscore the need for caution in evaluating and treating infants with suspected plagiocephaly. Rather than surgery or helmet therapy, many infants with mild skull flattening will be helped by spending some time each day playing in the prone position. This "tummy time," with other appropriate stimulation, also promotes upper body strength and coordination.

The Editors of Journal of Craniofacial Surgery hope that these and future studies will help in understanding and managing the "new epidemic" of positional plagiocephaly. Dr. Habal emphasizes the need for further studies to determine the causes of cranial bone softening and clarify the risks vs benefits of sleep position in infants.

What is positional plagiocephaly and how is it treated?

Plagiocephaly simply means flattening of the skull. Plagiocephaly in infants seems much more frequent than it was a decade ago; craniofacial surgeons report that babies with plagiocephaly now make up about 15 percent of patients seen in their daily practice. Many surgeons link the increase in "positional" plagiocephaly to the American Academy of Pediatrics' "Back to Sleep" campaign, which seeks to prevent SIDS by recommending that infants be placed on their backs to sleep.

Treatment options for plagiocephaly depend on the severity of skull flattening: in mild cases, placing the infant on his or her belly each day for some "tummy time" may be all that is needed. Other infants are treated with special custom-made helmets, which gradually correct the skull shape through gentle pressure. A relatively simple surgical procedure is another option, but is usually reserved for infants with severe plagiocephaly.